HH^HMHW 





LIBRARY OF CONGRESS, 

\?<^ 

Chap.,./r..:. Copyright No. 

T* 

ShellJitl. 



UNITED STATES OF AMERICA. 



THERAPEUTICS 



OF 



INFANCY AND CHILDHOOD 




a: JACOBI, M.D. 



CLINICAL PROFESSOR OF THK DISEASES OP CHILDREN IN THK COLLEGE OF PHYSICIANS AM' 
SUHGBONS (COLUMBIA UNI VEKSITY), NEW YORK; LATE PRESIDENT OF THE ASSOCIA- 
TION OF AMERICAN PHYSICIANS; OF THE NEW YORK ACADEMY OF MEDICINE. 
OF THE MEDICAL SOCIETIES OF THE COUNTY AND OF THE STAT1 01 
NEW YORK, ETC. J FOREIGN MEMBER OP THE MEDICAL SOCIETY 
OF wurzbukg; OF THE OBSTETRICAL SOCIETY OF BERLIN, 
OF THE ASSOCIATION FOR INTERNAL MEDICINE OF 
BERLIN; OF THE ROYAL MEDICAL SOCIETY OF 
BUDA-PESTH, ETC. 



SECOND EDITION 




PHILADELPHIA 

J. B. LIPPINCOTT COMPANY 
1808 



TWO COPIES HECE1VED 



#0 



2935 

Copyright, 1895, by J. B. Lippincott Company. 
Copyright, 1898, by J, B. Ltppincott Company. 



THIS BOOK 

is 

INSCRIBED TO THE CHIEF OF MY CLINIC, 

DR. FRANCIS HUBER, 

IN DUE APPRECIATION OF THE VALUABLE AND UNREMITTING 

SERVICES RENDERED BY HIM THESE SEVENTEEN 

YEARS TO ME AND TO THE 

COLLEGE OF PHYSICIANS AND SURGEONS OF NEW YORK, 

AND TO OUR STUDENTS. 



"Die Frucht der Heilung wachst am Baume der Erkenntniss. 
Ohne Diagnostik keine verniinftige Therapie. Erst untersuchen, dann 
urtheilen, dann helfen." — C. Gerhardt. 



PREFACE TO FIRST EDITION 



Much of what is contained in this work may be claimed as 
common property. Much of it I have taught before. Indeed, 
very few books can ever be written that will be entirely new. 
Paediatrics is not new to-day; nor was it so when, in 1860, I 
established the first systematic course, in our country, of clini- 
cal instruction in the diseases of children. Having since that 
time appeared before the medical public with essays and mono- 
graphs only, I was repeatedly reminded by friends of my ob- 
ligation to submit to the profession which lias afforded me so 
many facilities and advantages a compact picture of the thera- 
peutics of infancy and childhood as I have it in my mind. 

A large part of this work is devoted to diet and hygiene, a 
.good deal also to the consideration of the action of medicines. 
For, indeed, I believe in medicines. Advancing years and ex- 
perience during a period of increasing exactness in medical 
methods have rather strengthened my belief than otherwise. 
What the knife is to the surgeon, drugs are to the physician. 
The knife does not make the surgeon, nor do medicines make 
the physician; both, however, are indispensable. To employ 
them with benefit takes skill and experience, both individual 
and collective, as also judgment and honesty. 

Indications for the administration of medicines are fur- 
nished by etiology and symptomatology. Both of these oc- 
cupy a prominent place in this book. "Without a diagnosis of 
the morbid process and of its evolution, and without the ap- 
preciation of its influence on the patient, no rational therapy 
can be thought of. Consequently I have taken particular pains 
to offer clear, though brief, statements of differential diag- 
noses. 



VI PREFACE. 

I have tried to write a book for those who are sufficiently 
prepared by previous studies to build their therapeutical meas- 
ures on the foundation of an exact recognition of the condi- 
tions they have to deal with. It is intended for those to whom 
neither the principles of diagnosis nor the facts of materia 
medica are mysteries. Therefore, I have abstained from orna- 
menting my pages with numerous recipes. While aiming at 
accuracy in dosing, I have trusted, as regards the actual writing 
of prescriptions, to the knowledge and intelligence of the 
reader. On account of our present period of transition to the 
metric system, I beg to be pardoned for alternating the old 
methods with the new. 

In view of what I have included within the frame of this 
volume, it might almost claim the name of text-book. I prefer, 
however, to call it therapeutics only, intending to emphasize 
the fundamental truth that everything in medical science, in 
order to be both scientific and humanitarian, should be con- 
ducive to the prevention or to the cure of disease. 

The preparation of this book has extended over a long 
period. The first essays embodied in it were published in the 
Archives of Pediatrics of 1888. As a consequence the reader 
may discover occasional incongruities, which, however, he will 

find to be more those of style than of matter. 

A. Jacobi. 
110 West Thirty-Fourth Street, New York, 
October, 1895. 



PREFACE TO SECOND EDITION 



The revision of this book was begun immediately after its 
publication. The criticisms of reviewers and of correspondents 
have been carefully considered and taken advantage of. The 
final composition of the work as I now offer it represents the 
labor of a few months. In this way the drawbacks, resulting 
from the fact that the book which was commenced in 1888 was 
not published until 1896, were avoided. 

Some of the chapters are entirely rewritten; a few new ones 
are added; there is hardly one that has not been somewhat 
enlarged or otherwise changed. Indeed, every page has been 
scrutinized. In order to adapt the book more to the wants of 
the practitioner I have, while still adhering to the general 
views expressed in my former preface, been more explicit in the 
discussion of doses of drugs, and have added to the text a num- 
ber of prescriptions. Altogether I have tried to avoid ver- 
bosity, to condense my teaching in as few words as possible, and 
thus, while conveying knowledge to the beginner in a most 
concise shape, to offer the well-informed medical man a reper- 
tory of the science and art of modern paediatrics, with the 
addition of my own views and experience. The remark made 
by critics, that the book is a personal one, I wish to deserve. 

A. Jacobi. 

December 16, 1897. 



CONTENTS. 



I. Feeding of Sick Children 9 

Dietetics, no universal rules, 9 ; inanition, 10 ; oral secretion, oral 
glands, pancreas, digestion of starch, 11 ; stomach digestion, 12; 
in abnormal conditions, 13; water in food, 14; its effects, 15; 
sugar, 16, 31 ; chloride of sodium, 17 ; fat, 18; fa?ces, substitutes 
for breast-milk, 21 ; cereals, 22, 29 ; boiling of milk, 23 ; intesti- 
nal infection, 24; infected breast-milk, 24; sterilization, 25; its 
drawbacks, 26 ; casein of different milks, 27 ; dilution of food, 
30 ; milk modifications, 32 ; meat preparations, 40 ; peptones, 41 ; 
egg, 42 ; artificial foods, 43 ; alcohol, 44 ; dyspepsia, 45 ; vomit- 
ing, 46 ; gastritis, 47 ; chronic gastric catarrh, 48 ; ulceration of 
stomach, 48 ; enteritis, 50 ; constipation, 51 ; rhachitis, 52 ; fever, 
54 ; typhoid fever, 55 ; hereditary syphilis, cerebral diseases, 
respiratory diseases, 56 ; acute renal diseases, acute rheumatism, 
rectal alimentation, 57 ; forcible feeding, 59. 

n. General Therapeutics 60 

Diagnosis, expectant treatment, 60; preventive treatment, hy- 
giene, 62 ; bathing, hydrotherapy, 63 ; administration of medi- 
cines, 66 ; effects of medicines, 67 ; doses, 68 ; continuous medica- 
tion, 69 ; mode and locality of administration, 69 ; organotherapy, 
70; rectal administration, 71; suppositories, 74 ; subcutaneous 
injections, 74; serumtherapy, 77; anaesthesia by infiltration, in- 
halation, 78; gargles, skin, 84; sinapisms, vesicatories, 84; ice, 
86 ; fomentations, 86 ; depletion, 87. 

Ill Treatment of the Newly-Born 88 

1. Asphyxia 88 

2. Postnatal Asphyxia and Atelectasis 94 

3. Kephalhaematoma 97 

4. Hematoma of the Sterno-Cleido-Mastoid Muscle 98 

5. Sclerema 99 

1 ix 



X CONTENTS. 

PAGE 

6. Bathing 100 

7. Mamma, Mastitis, Perimastitis, Angioma 103 

8. Treatment of the Cord 106 

9. Omphalitis 109 

10. Umbilical Gangrene 109 

11. Arteritis and Phlebitis 109 

12. Puerperal Sepsis, Acute Patty Degeneration, Epidemic 

Hemoglobinuria Ill 

13. Umbilical Hemorrhage 112 

14. Icterus 113 

15. Melaena Neonatorum 114 

16. Trismus and Tetanus 115 

17. Blennorrhea 117 

13. Umbilical Fungus (Granuloma), Adenoma 118 

19. Hernia 119 

20. Congenital Constipation 121 

IV. Diseases of the Blood and Constitution 123 

1. Anaemia 123 

Pood, 125 ; insufficient innervation, iron, 128 ; oxygen, 
arsenic, 128 ; spermin, 131 ; pernicious anaemia, 132 ; leu- 
cocythaemia, 133 ; pseudoleukaemia, splenic anaemia, 134. 

2. Ehachitis 134 

Digestive disorders, 136 ; craniotabes, 140 ; laryngismus 
stridulus, 143 ; respiratory organs, 144 ; constipation, 146. 

3. Scrofulosis 147 

Preventive and curative treatment, 147 ; lymph-bodies, 
151. 

4. Lymphatism 153 

5. Diseases of the Ductless Glands 155 

Thyroid gland, goitre, 155; cretinism, 156; exophthal- 
mic goitre, 158 ; thymus, 160 ; akromegaly, Addison's 
disease, 161. 

6. Hemorrhagic Diathesis 163 

"Werlhof's disease, scurvy, peliosis rheumatica, haemo- 
philia, 163 ; infantile scurvy, 165. 

7. Diabetes 166 

Diabetes mellitus, 166 ; insipidus, 168. 

V. Infectious Diseases 169 

1. Tuberculosis 169 

Acute miliary tuberculosis, 170; tubercular phthisis, 



CONTENTS. XI 

PAGE 

170; causes, 172; inhalation of bacilli, 173; arsenic, 
179; digitalis, 180; creosote, guaiacol, 182; ichthyol, 
183; tuberculin, 184; operative procedures, larynx, 185; 
tongue and pharynx, 186; fistula in ano, 187; hemor- 
rhages, 188; night-sweats, 189. 

2. Syphilis 189 

Diet, 189 ; prevention, 191 ; treatment, 192. 

3. Intermittent Fever 197 

4. Typhoid Fever 200 

Preventive treatment, abortion, 201 ; general treatment, 
202 ; feeding, bronchitis, high temperatures, 203 ; tym- 
panites and meteorismus, 205 ; diarrhoea, 206 ; constipa- 
tion, perforations, hemorrhages, 207 ; heart-failure, 208 ; 
brain symptoms, 209; convalescence, consecutive dis- 
eases, 212; typho-malaria, 213. 

5. Typhus Relapsing Fever, "Weil's Disease 213 

6. Epidemic Cerebro-Spinal Meningitis 213 

7. Glandular Fever 215 

8. Catarrhal Fever 217 

9. Asiatic Cholera 217 

10. Dysentery 219 

11. Scarlatina 226 

Prevention, 227 ; rules of the New York Health Depart- 
ment, 230; methods of disinfection, 232; disinfection 
and disinfectants, 234 ; medicinal treatment, 235 ; rheu- 
matism, the heart, joints, 238 ; respiratory organs, hemor- 
rhages, pemphigus, 239 ; complications, 240. 

12. Measles 241 

Hemorrhagic measles, respiratory organs, 243 ; kidneys, 
brain, 244. 

13. Rotheln (Rubella) 245 

14. Mumps 245 

15. Variola, Variolois 246 

16. Varicella (Chicken-Pox) 247 

17. Vaccinia 247 

18. Erysipelas . 2-19 

19. Diphtheria 252 

Prevention, 254 ; relation to mucous membranes, 259 ; 
potassic chlorate, 260 ; heart-failure, 261 ; local treatment, 
264 ; nose, 267 ; treatment, 269 ; adenitis, 271 ; internal 
treatment, 272 ; nephritis, 276 ; paralysis, antitoxin, 277. 

20. Rheumatism 285 



Xll CONTENTS. 

PAGE 

Acute articular rheumatism, 288 ; endocarditis, 292 ; gon- 
orrhoeal rheumatism, 294; rheumatismus nodosus, peli- 
osis rheumatica, 295; erythema, 296; chronic articular 
rheumatism, 297 ; muscular rheumatism, 298. 

21. Influenza 299 

22. Pertussis 300 

VI. Diseases of the Nervous System 311 

1. General Indications 311 

Polyneuritis, hemicrania, muscular atrophy, progressive 
juvenile muscular dystrophy, pseudohypertrophy, con- 
genital myotony, 315. 

2. Operations 316 

Microcephalus, idiocy, 316 ; brain tumors, 317. 

3. Inflammatory and Exudative Processes, Arrests of Develop- 

ment 318 

Cerebral meningitis, 318 ; hyperaemia, 319 ; thromboses, 
embolism, 320 ; tubercular meningitis, 321 ; lumbar 
puncture, 223 ; general paralysis, chronic hydrocephalus, 
324 ; disseminated sclerosis, infantile spastic hemiplegia, 
bulbar paralysis, meningocele, encephalocele, meningo- 
cele spuria, 328. 

4. Psychical Diseases 329 

Dementia, mania, melancholia, moral insanity, monoma- 
nia, epileptic and circular dementia, paresis, delirium tre- 
mens, 329 ; idiocy, cretinism, 330 ; Pavor nocturnus, 333. 

5. Spinal Inflammations, Genuine and Infectious, and Arrests 

of Development 333 

Pachymeningitis, leptomeningitis, transverse myelitis, 
sclerosis, paramyoclonus, tabes, Landry's paralysis, polio- 
myelitis, 337 ; club-foot, 339 ; hydrorrhachis, 334, 340 ; 
tetanus, 341. 

6. Neuroses of Central or Local Origin 342 

Eclampsia, 342 ; chorea minor, 343 ; tetany, 345 ; cata-* 
lepsy, 346 ; chorea magna, 347 ; athetosis, 348 ; epilepsy, 
348 ; salaam spasm, 354 ; stammering, 355. 

VII. Diseases of the Digestive Organs 356 

A. The Mouth 356 

1. Hare-Lip and Fissure of the Palate 356 

2. Tumors in the Oral Cavity 356 

3. Kanula 357 



CONTENTS. Xlll 

PAGE 

4. Milia, Epithelial Pearls 357 

5. Stomatitis 358 

6. Bednar's " Aphthae" 359 

7. Thrush 360 

8. Infectious Stomatitis 361 

9. Noma 361 

10. Sublingual Adenitis 361 

11. Parotitis 362 

12. Difficult Dentition 362 

13. Dental Ulceration, Riga's Disease 363 

B. The Tongue 363 

1. Congenital Anomalies 363 

2. Glossitis 364 

C. The Throat 365 

1. Pharyngitis, including Amygdalitis ("Tonsillitis") 365 

2. Retro- and Latero- Pharyngeal Abscess 367 

3. Adenoid Vegetations 369 

4. Fistula Colli Congenita 370 

D. The (Esophagus 371 

E. The Stomach 237 

1. General Nosology, Dyspepsia t 372 

2. Acute Gastric Catarrh 378 

3. Gastritis 379 

4. Chronic Gastric Catarrh 380 

6. Dilatation of the Stomach 381 

6. Nervous Dyspepsia 383 

7. Gastric Ulceration 383 

F. Intestinal Diseases 387 

1. Constipation 387 

Actual constipation, apparent constipation, me- 
chanical obstruction, 389; membranous enteritis, 
incomplete peristalsis, 389 ; colic, 392. 

2. Diarrhoea 383 

Bacteric, 395 ; acid, 397 ; acute intestinal catarrh, 
399; " summer" diarrhoea, 400. 

3. Tumefaction of the Mesenteric Lymph-Bodies . . . 401 

4. Appendicitis 403 

5. Paratyphlitis 406 

6. Intussusception 407 

7. Helminthes 409 

8. Umbilical Hernia 412 

9. Inguinal Hernia 413 



XIV CONTENTS. 

PAGE 

10. Catarrh of the Kectum 414 

11. Prolapse of the Anus and Kectum 414 

12. Fissure of the Anus 417 

13. Polypus of the Eectum 418 

G. The Liver . 419 

Enlargement, 419 ; hepatoptosis, fatty infiltration, 
420; cirrhosis, 421; congestion, inflammation and 
suppuration, acute yellow atrophy, jaundice, 422 ; 
echinococcus, 423. 

H. The Spleen 424 

Enlargement, embolism, abscesses, 424 ; perisplenitis, 
424. 
I. Peritonitis 425 

VIII. Diseases of the G-enito-TJrinary Organs 430 

1. The Kidneys 430 

Preventive treatment, uric acid infarction, 430 ; mal- 
formations, pseudoplasms, primary tuberculosis, 431 ; 
echinococcus, hydronephrosis, floating kidney, haema- 
turia, hemoglobinuria, 432 ; nephritis, causes, 433 ; 
acute, 435 ; subacute, 436 ; chronic, 437 ; renal calculi, 
439. 

2. The Bladder 441 

Cystitis, 441 ; spasm, retention, incontinence, 442, 444; 
dysuria, irritable bladder, 443 ; retention, 443 ; muscu- 
lar debility, 444 ; reflex contraction, irritability of the 
neck, 446. 

3. Other Organs : Anomalies and Diseases 447 

Development, 447; epithelial obstruction, membranous 
obstruction ; imperforation of the glans, strictures, hy- 
pospadias, 448 ; prepuce, 449 ; phimosis, 451 ; diph- 
theria of the prepuce, aphthous vulvitis, 454 ; noma 
of the vulva, paraphimosis, 455 ; balanitis, balanopos- 
thitis, vulvar and vaginal catarrh, 456 ; atresia, imper- 
forate hymen, vaginal hemorrhage, masturbation, 458 ; 
cryptorchis, 459; orchitis, tuberculosis, syphilis, hy- 
drocele, 460 ; neoplasms, 460, 461. 

IX. Diseases of the Respiratory Organs 463 

1. Nares 463 

Acute nasal catarrh, 463 ; chronic, 465 ; polypus, 467 ; 
foreign bodies, 468 ; epistaxis, 469 ; ulceration, 470. 



CONTENTS. XV 

PAGE 

2. Chronic Laryngeal Catarrh 472 

Diphtheritic laryngitis, pseudo-membranous croup, 473 ; 
neurotic affections, spasm of the glottis, 477 ; paralysis of 
the glottis, neoplasms, 478. 

3. Bronchi 479 

Bronchial catarrh, bronchitis, 479 ; chronic, fibrinous, 
481 ; asthma, 482 ; periodic night-cough, 483. 

4. Lungs 483 

Pneumonia, 483 ; interstitial, emphysema, 495 ; pul- 
monary oedema, pulmonary hemorrhage, infarction, 496; 
gangrene, pseudoplasms, echinococcus, actinomycosis, 
hernia of the lungs, funnel chest, 497. 

5. Intrathoracic lymph-bodies 498 

6. Pleura 499 

Pleurisy, 499 ; hydrothorax, pneumothorax, pyopneu- 
mothorax, 510. 

X. Organs of Circulation 511 

1. Heart 511 

Acute and chronic diseases, 511 ; myocarditis, 323 ; endo- 
carditis, 524 ; pericarditis, 527 ; congenital anomalies, 
congenital undersize, 529. 

2. Blood-vessels 530 

Hypoplastic state, aneurism, 530; thrombosis, 531; 
naevus, angioma, 532. 

3. Lymph- Vessels 534 

Lymphangioma, elephantiasis, chyluria, cystic lymphan- 
gioma, 634. 

XI. Diseases of the Skin 535 

Burns, 535 ; frost-bites, 536 ; erythema, 537 ; erythema nodo- 
sum, intertrigo, 539 ; acne, lichen, prurigo, 540 ; lichen scrofu- 
losorum, 541 ; furunculosis, 542 ; eczema, impetigo, ecthyma, 
rupia, 543 ; eczema seborrhoicum, pemphigus, 546; dermatitis 
exfoliativa, pemphigus foliaceus, 547 ; pemphigus exfoliativus, 
neuropathic affections, papilloma, pemphigus neuroticus chroni- 
cus, oedema, cyanosis, 548 ; symmetrical hemorrhage, erythro- 
melalgia, gangrene, scleroderma, scabies, 549 ; impetigo conta- 
giosa, favus, 550; herpes tonsurans, molluscum contagiosum, 
lupus, 551 ; lupus erythematosus, tuberculosis of the skin, 
scrofuloderma, 552 ; psoriasis, congenital diseases, 553 ; ich- 
thyosis, neoplasms of the neck, naevus pigmentosus, verrucosus, 
lipomatodes, 555. 



XVI CONTENTS. 

PAGE 

XII. Diseases of the Muscles 557 

Myositis, 557 ; paralysis, 558 ; myasthenia, torticollis, 559. 

XIII. Diseases of the Bones and Joints 562 

Congenital anomalies, 562; exostosis, 563; congenital luxa- 
tions, 564 ; bones, fractures, 566 ; chondritis, 567 ; peritonitis, 
ostitis, 567 ; spondylitis, 569 ; arthritis deformans, 571 ; joints, 
572; coxitis, 579; gonitis, 580; ankle- and tarsal-joints, 
elbow, genu valgum, 581 ; pes varus, 582 ; equinus, cal- 
caneus, 583 ; valgus, 584 ; scoliosis, 585 ; kyphosis, 586. 

XIV. Diseases of the Ear 587 

Malformations, foreign bodies, 587 ; otitis externa, 588 ; my- 
ringitis, 589 ; polypus, 590 ; otitis media, 591 ; mastoid 
process, 594 ; deaf-mutism, 595. 

XV. Diseases of the Eye 596 

Malformations, neoplasms, 596 ; foreign bodies, 597 ; injuries, 
blepharitis, 598; conjunctiva, 599; conjunctivitis, 600; 
diphtheritic, 601 ; trachoma, 602 ; keratitis, 603 ; keratoconus, 
iritis, 605 ; cyclitis, vitreous body, choroid, cataract, 606 ; 
retina, optic nerve, orbit, glaucoma, strabismus, 607. 



THERAPEUTICS 

OF 

INFANCY AND CHILDHOOD. 



FEEDING OF SICK CHILDREN. 

Dietetics must be considered a part of therapeutics. The 
two must always go hand in hand. Sydenham knew the fact 
that many diseases are removed by a correct mode of living, 
and nutrition; and the men who established therapeutical 
schools on certain positive principles or on preconceived ideas 
arranged their dietetical and their medicinal and surgical rules 
on the same basis. Thus, Broussais, among others, while he 
purged and bled, crowned his work with starvation to such an 
extent that Graves, in 1843, had to come forward with the 
declaration that the systematic starvation of the disease ended 
in the destruction of the patient. It was Chossat, finally, who 
proved that inanition had many of the symptoms of fever, and 
that a starvation diet was liable to increase its dangers. 

Still, there are no universal rules for feeding, as there are 
none for medication. There are, however, certain indications 
which can always be fulfilled in the treatment of individual 
cases. As intellect and knowledge are required for finding 
those indications, so there is need of tact and experience to 
apply and fulfil them. Some of them are plain enough. It 
is clear that in conditions of great debility there must be no 

9 



10 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

further reduction of strength; an irritated cerebrum should not 
be excited; hemorrhages, peritonitis, dysentery, perityphlitis 
require absolute rest; a hypersesthetic stomach must not be 
overfed; a gastro-enteritis resulting from the presence of fer- 
ments should do without milk; convalescence should be 
shielded and acute inflammatory fevers guarded. Still, there 
are chronic fevers with fair digestion which permit of generous 
feeding. All these indications and rules are equally valid for 
both the adult and the young. Still, the latter have some pecu- 
liarities which alter the application of general rules to a con- 
siderable extent, for several reasons. Of these I shall mention 
but a few at this time. Habits, which play an all-important 
part in the nosology of adults, such as alcohol, narcotics, sexual 
abuses, are not observed — unless very exceptionally — in the 
child. Cardiac debility, which is the constant danger of the 
senile period, and a frequent one in the adult, is in the begin- 
ning of a morbid process not so frequent in the very young, 
partly because the heart, compared with the rest of the body, 
is larger and more powerful, and partly because it has not had so 
much time and opportunity to become diseased. On the other 
hand, general metamorphosis is very rapid in the young, be- 
cause both of the rapidity of the vital processes, and of the 
constant necessity of adding to the tissues of the body, besides 
keeping up the equilibrium. Therefore inanition is not toler- 
ated for a long time. Thus the child cannot long remain with- 
out being fed, and, therefore, its digestive organs require per- 
manent attention. Their physiology must be carefully studied 
both in the healthy and morbid conditions. What the child 
eats is important, but of little consequence compared with what 
it digests. Nor are its subjective sensations the proper guides 
for the selection of foods or for the times of feeding. It is not 
always true that where there is no appetite there is no diges- 
tion. Nor are the pangs of hunger or the temptations of 
whimsical cravings safe counsellors. Nor does the condition of 
the tongue, to which we are apt to turn as one of our advisers 



FEEDING OF SICK CHILDREN. 11 

in many of the ailments of the adult, deserve the same con- 
fidence in the young, for the frequent local processes inside 
the oral cavity are very apt to mislead us. 

From the very first month of life a distinct diastatic effect is 
produced by the oral secretion; it increases with every month. 
Even infusions of the parotids, prepared at different times 
after death, produce the same effect. Infusions, however, of 
the pancreas taken from the bodies of infants who have lived 
three weeks produce no such changes. The diastatic power of 
the pancreas begins with the fourth week only, and remains 
feeble up to the end of the first year. Kriiger (1891) found 
in the foetus of seven months a sugar-forming ferment which 
increases towards the normal end of intrauterine life, is still 
small in quantity at birth, but grows so rapidly that it is as 
active about the eleventh month of life as it is in the adult. 

Zweifel experimented with infusions of different glands. 
That of the submaxillary glands of an infant did not trans- 
form starch into sugar, even after the lapse of a whole hour. 
The effect of an infusion of the parotid of a baby seven days 
old was distinct after four minutes; however, that of the 
parotid of a baby which had died at the age of eighteen days, 
of gastro-enteritis, did not act until the lapse of three-quarters 
of an hour. ~Not was a diastatic result obtained by a similar 
infusion made of the parotids of a baby prematurely born, and 
one who died of diarrhoea and debility. 

It is a remarkable fact that different varieties of starch are 
not changed by saliva into grape-sugar in the same length of 
time. In reference to the time required, however, there is no 
uniformity of opinion. Solera found that the transformation 
of the starch of the potato was the most rapid. . Xext came 
that of Indian corn, next wheat, and the transformation of 
the starch of rice was the slowest. According to Malay, raw 
starch changes slowly, boiled starch quickly. According to 
him, that of the potato required from two to four hours; that 
of wheat from one-half to one hour; of barley from ten to 



12 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

fifteen minutes; of oats from five to seven minutes; of rye 
from three to six minutes.* 

It is important to know that the effect produced by saliva 
persists in the stomach for a period of from one-half to two 
hours. But it ceases altogether, and starch will no longer be 
changed into grape-sugar, inside the stomach, as soon as the 
secretion of hydrochloric acid has begun in the digestive pro- 
cess. This is a very important fact, because it shows that the 
farinaceous food of the infant or child, though it be not masti- 
cated, and pass the mouth very rapidly, is in the stomach still 
under the influence of the saliva. 

Hydrochloric acid is not secreted at once. The first acids 
in the stomach while digestion is going on are organic, mostly 
lactic. This is found to be contained in that organ when gas- 
tric juice is removed from it in the first period of digestion. 
Thus in a gastrostomized boy Uffelmann found under normal 
circumstances, and in the absence of fever, during the first 
half -hour, lactic acid only; afterwards hydrochloric acid.f The 

* When saliva is found insufficient at any age, medicinal aids are 
welcome. Taka-diastase has been recommended for the purpose of 
digesting starch. Friedenwald (N. T. Med. Journal, May 29, 1897) is 
very enthusiastic in its praise. "It is employed in hyperacidity. It 
converts one hundred times its weight of starch in ten minutes, and 
thereby replaces saliva. It continues its action in the stomach, stimu- 
lates gastric secretion, and promotes the motor function of the stomach, 
and thereby promotes the digestion of the proteids." 

t This agrees with what Ewald and Boas published as the result of 
their experiments also. But they claim to have found hydrochloric 
acid only when a decoction of starch alone was introduced into the 
stomach. Still later Th. Rosenheim (Centralbl. f. d. Med. Wiss., No- 
vember 12, 1887) reports as follows, after the ingestion of fifty grammes 
of bunn and one hundred and fifty of water: Free hydrochloric acid 
makes its appearance in the healthy stomach very early, 0.3 p. m. after 
fifteen minutes, 1.0 p. m. after thirty minutes. This quantity or more 
is found until the elimination of chyme has been completed. From 
beginning to end there is lactic acid to a uniform amount, — viz., 0.3 
p. m. In carcinoma there was but 0.1 p. m. of hydrochloric, acid, in 



FEEDING OF SICK CHILDREN. 13 

latter is not met with during fevers of any kind, provided the 
temperature is high, nor during a severe gastric catarrh (and 
also in dilatation of the stomach resulting from congenital or 
other constriction of the pylorus). In these conditions fari- 
nacea (amylacea) are taken to advantage, principally because 
the diastatic effect of saliva is not disturbed. 

Some of the main points to be remembered from the fore- 
going are these: 

There is diminution or absence of saliva from the parotid 
in the very young while suffering from diarrhoea and debility. 
It never is copious. Thus the very young when well ought to 
have but little starchy food, and when sick none at all, par- 
ticularly as the pancreas cannot be relied on for diastatic action 
in the first weeks. 

Whatever saliva, however, has been secreted and is swal- 
lowed, continues its action in the stomach as long as there is 
no hydrochloric acid in it. This in the healthy is secreted 
only after half an hour or later; in the feverish and catarrhal 
stomach very much later or not at all. Thus what saliva is 
present displays its diastatic action continually. Therefore 
the food craved for and digested by children, also by infants 
to a great extent, is, besides milk, farinaceous. Animal food 
which requires hydrochloric acid is not wanted, nor is it readily 
digested in the stomach. 

In anaemia, convalescence, particularly in fevers, the func- 
tions of the stomach are impaired. In them both pepsin and 



hyperacidity 1.0 p. m. In every case and in every period of digestion 
there was lactic acid. There was less hydrochloric acid (but 0.2 p. 
m. after an hour) and a fair amount of lactic acid when carbohydrates 
only were taken, no matter whether saliva was admitted to or excluded 
from the stomach. 

These data are here added for the purpose of showing that the diffi- 
culties of arriving at absolute facts are exceedingly great. Still, the 
results of the three observers do not differ too much from the accepted 
doctrine. 



14 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

hydrochloric acid are wanting. To increase their secretion 
large quantities of watee are required. 

Infants' food ought to be mixed with large quantities of 
water, not for the sick only, but under ordinary circumstances. 
In diseased conditions of the stomach the free dilution of chil- 
dren's nourishment with water is demanded upon the following 
additional facts. Only to a certain limit, if at all, will pepsin 
be furnished for digestive purposes. Probably a portion of this 
is not entirely utilized, because a great quantity of water is 
necessary to assist in pepsin digestion. In artificial digestion 
albumin often remains unchanged until large quantities of 
acidulated water are supplied. Without doubt many disturb- 
ances of digestion are to be explained by a deficiency of water, 
certainly many more than are due to an excess of it, for the 
latter is speedily relieved by rapid absorption. 

For the reasons given, I advocate under all conditions a 
plentiful addition of water to children's food. As a general 
observation, I would lay stress upon the fact that, as a rule, 
small children receive water only as they get it in their milk or 
milk food. Alike in summer and in winter, it is probable that 
the fact seldom occurs to a mother or nurse that a child may 
be thirsty without being hungry at the same time. Certainly 
many a discomfort and even sickness in a child is conditioned 
upon the fact that it has been compelled to eat in order to get 
its thirst satisfied, and often has to suffer thirst because the 
over-stimulated and injured stomach will take no more nour- 
ishment at irregular and too short intervals. There are even 
normal products of digestion that are capable of disturbing 
the digestive process, chief among which is peptone itself, 
which is not absorbed unless it be greatly diluted. That is 
why I, when preparing the rules for the feeding of children, 
which the New York Health Department has annually pub- 
lished and distributed, these several decades, insisted upon 
giving infants, who cannot ask in so many words for it, an 
occasional drink of water, at least during the hot weather. 



FEEDING OF SICK CHILDEEN. 15 

When there is the least ground for the supposition that the 
drinking-water is contaminated with germs of disease, or where 
it is unusually hard, it should be boiled before its admixture 
with children's food, whether the diet be milk or a mixed one. 
In general it will give greater satisfaction to give very young 
infants boiled water as a matter of course, even though there 
be no apparent urgency for it. 

There are many other indications for the administration of 
water in the diseases of the young. In many morbid condi- 
tions it is wanting. Perspiration, diarrhoea, general inanition, 
feverish diseases, diminish its quantity in the tissues and blood- 
vessels. Thus an inspissation of the blood takes place, throm- 
boses form in the small veins of distant parts or the viscera, 
in the brain they lead to convulsions and defective innerva- 
tion (hydrencephaloid), in the limbs to oedema or gangrene. 
The remedy is water in sufficient quantities. Where the 
stomach rebels, the hungry lymph-ducts of the rectum will 
greedily absorb an ounce or much more, injected every hour 
or two. In many a case life is saved in this manner. In ex- 
treme cases the subcutaneous infusion of a sterilized salt-water 
solution (6 : 1000) is required. From two to six hundred cubic 
centimetres (six to twenty ounces) will readily be absorbed in 
the subcutaneous tissue. 

Where general metamorphosis is slow, water in abundance 
increases the elimination of urea and carbonic acid. Where 
the urine is scanty and of an undue specific gravity, water 
protects the kidneys from undue irritation. It acts on the 
mucous membranes as it does on the external integuments. 
In laryngitis and bronchitis it liquefies viscid expectoration, in 
many forms of constipation it acts beneficially by increasing 
the secretion of the muciparous glands of the intestines. Ice 
and ice-water, or iced carbonated water, in small quantities, but 
frequent doses, relieve hyperesthesia of the stomach and stop 
vomiting. Warm water acts as an emetic, hot water injected 
into the rectum combats collapse. In connection with this sub- 



16 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

ject, however, I may allude to what good may be done by absti- 
nence from water. In some forms of acute gastro-enteritis, 
where vomiting and diarrhoea are excessive, the only salvation 
is in total abstinence for from four to eight or ten hours. Not 
infrequently the turning-point in the course of the threatened 
danger dates from the commencement of what appears to be 
cruel starvation. 

A regular addition to the milk food of infants and children 
is that of sugar. Its percentage in the milk of the woman, 
ass, and mare is larger than that of the cow. Immediately 
after the milking of the cow the milk-sugar begins, to be 
changed into lactic acid. This process, after rennet has exerted 
its coagulating effect, together with the gradual conversion of 
fat into acid, is the final cause of curdling. The large amount 
of sugar in woman's milk, together with its smaller percentage 
of casein (about one per cent.) and butter, gives it the peculiar 
bluish color and furnishes the colostrum of the first days after 
birth, which contains plenty of salts besides, its tendency to 
loosen the bowels. This property becomes manifest, some- 
times, under abnormal circumstances. Thus in the milk of 
anaemic women sugar is occasionally found to an unusual de- 
gree. In their cases the other solid matters may also be di- 
minished, still, this is not uniformly so. The infants, however, 
suffer often from obstinate diarrhoea. 

The conversion of milk-sugar into lactic acid takes place 
very rapidly. Under its influence cow's milk turns sour at 
once. Not infrequently is it acid from the first; it has been 
found to be so in the udder; in most cases it is "amphoteric," 
neutral. Thus the question arises what kind of sugar is to be 
used as the addition to the food of children both well and sick. 

Cane-sugar is not so easily transformed. Indeed, it is util- 
ized for the purpose of counteracting the rapid conversion of 
milk-sugar, and for the preservation of articles of food in 
general. Trade is not so slow in availing itself of the results 
of organic chemistry as the profession. Condensed milk re- 



FEEDING OF SICK CHILDREN. 17 

mains unchanged a long time, on account of the plentiful addi- 
tion of cane-sugar, in spite of the original presence of milk- 
sugar in it. Therefore it is not at all an indifferent matter 
whether milk-sugar or cane-sugar be added to the food of in- 
fants and children. I have always insisted upon the selection 
of the latter for that purpose. Biedert employs cane-sugar in 
his cream mixture. 

In the sick the absorption of sugar is slower than in the 
healthy. Besides, during most diseases, particularly those of 
the alimentary canal, there is more abnormal ferment in the 
mouth and stomach. Thus but little sugar ought to be given, 
and never in a concentrated form. Grape-sugar, and dextrin 
are absorbed equally. Cane-sugar, according to Pavy, is partly 
inverted into grape-sugar and partly absorbed. All appear to 
be changed, when given in moderate quantities, into carbonic 
acid and water, even during moderate fevers. 

In that form of constipation of small infants which depends 
on a relative absence of sugar and superabundance of casein 
in the breast-milk, the addition of sugar acts very favorably. 
A piece of loaf-sugar (a teaspoonful or less) dissolved in tepid 
water (or oatmeal water) should be given before each nursing, 
and will often prove the only remedy required to regulate the 
bowels. 

The physiological effect of chloride of sodium is very im- 
portant, no matter whether it is directly introduced through 
the mother's milk, or added as a condiment to cow's milk, or to 
vegetable diet. Both of the latter contain more potassium 
than sodium, and neither ought ever to be given, to the well or 
sick, without the addition of table-salt. A portion of that 
which is introduced may be absorbed in solution; another part 
is, however, broken up into another sodium salt, and hydro- 
chloric acid. Thus it serves directly as an excitant to the secre- 
tion of the glands, and facilitates digestion. Therefore during 
diseases in which the secretion of gastric juice is interfered 
with, or in the beginning of convalescence, when both the 

2 



18 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

secreting faculties and the muscular power of the stomach are 
wanting, and the necessity of resorting to nitrogenous food is 
apparent, an ample supply of salt ought to be furnished. The 
excess of acid which may get into the intestinal canal unites 
with the sodium of the bile in the duodenum, and assists in 
producing a second combination of chloride of sodium, which 
again is dissolved in the intestines and absorbed. Its action 
in the circulation is well understood: it enhances the vital 
processes, mainly by accelerating tissue-changes through the 
elimination of more urea and carbonic acid. 

A very important fact is also this: that the addition of 
chloride of sodium prevents the too solid coagulation of milk 
by either rennet or gastric juice. Thus cow's milk ought never 
to be given without table-salt, and the latter ought to be added 
to woman's milk when it behaves like cow's milk in regard to 
solid curdling and consequent indigestibility. 

Habitual constipation of children is also influenced bene- 
ficially, for two reasons: not only is the food made more digest- 
ible, but the secretions of the alimentary canal, both serous and 
glandular, are made more effective by the presence of sodium 
chloride. 

A certain amount of fat is digested even in fevers of mod- 
erate severity, thus also in typhoid fever. But it is a good rule 
to rather reduce its quantity, because when infants were fed on 
cow's milk during capillary bronchitis, the fat in the fasces 
amounted to forty per cent, of the solid constituents. A few 
additional remarks will render the subject clearer, and show 
that it is very easy to give too much fat. 

Infant faeces are comparatively copious, although the baby 
receive absolutely nothing but mother's milk. What has been 
called detritus in the faeces is not exclusively undigested casein, 
but principally fat and large masses of intestinal epithelium. 
This so-called detritus is not soluble in water, acids, or alkalies, 
but quite soluble in alcohol and ether. Casein is present only 
when it has been taken in too large a quantity, or when there is 



FEEDING OF SICK CHILDREN. 19 

too much free acid in the stomach. In those cases there are 
large quantities of it in the fasces. 

An important practical application of this fact is the follow- 
ing: As it is true that fat is not completely absorbed, even 
under the most normal circumstances; as free fat acids are so 
easily formed and accumulated; as they are found in moderate 
quantities, even in healthy babies; as a surplus is very apt to 
derange digestion and assimilation, and to prevent the normal 
secretion of either of the digestive fluids; as there is a super- 
abundance of fat in the normal food of the nursling, the con- 
clusion is justified that we should be very careful in preparing 
foods for the healthy or sick. It is very easy to give too much 
fat. It is hardly probable that there is too little. 

V. and I. S. Adriance have succeeded in proving, by exact 
chemical and clinical researches, some facts which were known, 
but perhaps not sufficiently appreciated. Both excessive fats 
and proteids in the milk of the mother may cause gastro- 
intestinal symptoms in the nursing infant; the former may be 
reduced by diminishing the nitrogenous elements in the 
mother's diet; the latter by the proper amount of exercise. 
Excessive proteids are especially apt to cause gastro-intestinal 
symptoms during the colostrum period, and particularly during 
that of premature confinement, when their percentage is 
higher. Premature infants are, therefore, in particularly great 
danger, and their food ought to be greatly modified and 
watered. 

Under the head of "Pat Diarrhoea" German journals and 
a few text-books speak of a diarrhoea, the chief characteristic 
of which is the presence of a large quantity of fat in the stools. 

The normal faeces of the newly-born contain ten or twelve 
per cent., sometimes more, of fat. In abnormal cases, even 
when the food does not contain it, the faeces may contain from 
forty to seventy per cent, of fat. 

The microscope reveals in serious cases fat, almost to the 
exclusion of everything else, sometimes pure, and other times 



20 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

in more or less regular needles. The anatomical condition in 
fat diarrhoea may vary, but in the majority of cases we have 
to deal with a simple catarrh of the intestinal tract. There 
are changes in, and exfoliation of, the epithelium of the small 
intestine, swelling of the mucous membrane of the duodenum, 
with obstruction to the flow of the secretions of both liver and 
pancreas, and such hyperplasia of the mesenteric lymph bodies 
as to impede the absorption and circulation of chyle. Finally, 
in a very few instances, anatomical changes were found in the 
pancreas resembling those which in the adult interfere with 
the emulsion of fat. 

No improvement is possible unless the quantity of fat con- 
tained in the food be largely diminished. The administration 
of cream and the routine treatment with cod-liver oil are 
equally injurious in these cases; for even normal digestion 
disposes only of a limited quantity of fat (cream, butter, cod- 
liver oil); twenty-live per cent, of it in the food, as lately recom- 
mended (Berliner Minische Wochensclirift, June 14, 1897), is 
excessive. One of the preparatory stages of its assimilation is 
the formation of oleic acid; lipanin, which has been recom- 
mended in place of cod-liver oil, contains six per cent, of that 
acid, the physiological preparation of which the body is spared 
by its administration. There may be very few conditions in 
which the digestion is so low as not to insure the required 
transformation, but in chronic dyspepsia of different sorts fat 
is badly digested and absorbed, and lipanin may take its 
place. 

What is it that a sick infant, or child, ought to eat? That 
question is so grave because the young when quite well are 
easily disturbed in their health by mistakes in their diet; in- 
deed, the large majority of the diseases of infancy are those of 
the alimentary canal; and an error in diet during the course 
of a disease is liable to prove fatal. Advanced childhood is 
not so endangered; that is why my first remarks are due to 
infancy. If the literature dedicated to its physiological and 



FEEDING OF SICK CHILDREN. 21 

pathological conditions were as profitable as it is copious, the 
gain would be immense by this time. For, indeed, both the 
hygiene and the pathology and therapeutics of early age do 
not lack contributions. Particularly the former, being the 
main prop and staff of infant (as of all) therapeutics, has roused 
the zeal and industry of many workers; among them some of 
the very best of modern times. 

In feeding the sick no new principles must be sought for. 
The sick child is still the child, and the physiological laws 
hold their own under changed circumstances. No new articles 
of food can be discovered or invented, only the preparation or 
mixture of those in ordinary use may change temporarily, or a 
restriction in their number or amount may take place. Thus, I 
cannot undertake to give in full the methods of feeding in- 
fants and children. In several previous publications I have 
done so, and must refer to them. I will only repeat a few 
rules, leaving the reasons for them to the thoughtfulness or 
the recollection of the reader. 

The principal substitutes for breast-milk are those of the 
cow and the goat. The mixed milk of a dairy is preferable 
to that of one cow. Cow's milk must be boiled before being 
used. Condensed milk is not a uniform article, and its use 
precarious for that and other reasons. Goat's milk contains 
too much casein and fat, besides being otherwise incongruous. 
Skimmed milk obtained in the usual way, by allowing the 
cream to rise in the course of time, is objectionable, because 
such milk is always acidulated. The caseins of cow's and 
woman's milk differ both chemically and physiologically. The 
former is less digestible. There ought to be no more than one 
per cent, of casein in every infant food. Dilution with water 
alone may appear to be harmless in many instances, for some 
children thrive on it. More, however, appear only to do so; 
for increasing weight and obesity are not synonymous with 
health and strength. A better way to dilute cow's milk, and 
at the same time to render its casein less liable to coagulate 



22 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

in large lumps, is the addition of decoctions of cereals. It has 
been stated before, that a small amount of starch is digested at 
the very earliest age. But cereals containing a small per- 
centage of it are to be preferred. Barley and oatmeal have an 
almost equal chemical composition; but the latter has a greater 
tendency to loosen the bowels. Thus, where there is a ten- 
dency to diarrhoea, barley ought to be preferred; in cases of 
constipation, oatmeal. The whole barley-corn, ground for the 
purpose, should be used for small children, because* of the pro- 
tein being mostly contained just inside and near the very husk. 
The newly-born ought to have its boiled milk (sugared and 
salted) mixed with four or five times its quantity of barley- 
water, the baby of six months equal parts. Gum arabic and 
gelatin may also be utilized to advantage in a similar manner. 
They are not only diluents, but also, under the influence of 
hydrochloric acid, nutrients. Thus, in acute and debilitating 
diseases which furnish no, or little, hydrochloric acid in the 
gastric secretion, a small quantity of the latter, well diluted, 
must be provided for. This, my method of infant feeding, 
which is suited for the stomachs and purses of the rich and 
poor alike, is, however, not the only one proposed and found 
satisfactory. No single method, indeed, is the only one, nor 
does it suit every case. It is only an occasional chemist who 
expects the organic stomach to behave like a chemical reagent; 
clinicians, however, admit exceptions to the working of their 
rules and regulations, though their conception were ever so 
correct and physiological. Still the endeavors to improve the 
diet of the young, and thereby to remove the dangers of in- 
testinal disorders and the sources of excessive mortality and 
invalidism are going on. Nothing has been more successful 
in that direction than the wide-spread practice of sterilization 
and pasteurization of cow's milk. Both are the logical de- 
velopment of the plan of treating milk by boiling which I have 
persistently advised these forty years at least, and detailed in 
my "Infant Diet," in Gerhardt's "Handbuch," in Buck's 



FEEDING OF SICK CHILDREN. 23 

"Hygiene/' in "Intestinal Diseases of Infancy and Child- 
hood,"* and in my clinical lectures delivered during more 
than one-third of a century. There can hardly be a doubt 
that if raw milk could always be had unadulterated, fresh, and 
untainted, and as often as it was wanted, it would require no 
boiling. It would even contraindicate it, for high tempera- 
tures destroy not only some of the dangerous, but also those 
bacteria whose action is desirable for normal digestion. Be- 
sides, there are those who strongly believe that boiling causes 
chemical changes. But such ideal milk cannot be had so long 
as cows are tuberculous, scarlet fever and diphtheria are met 
with in the houses and about the clothing and on the hands 
of dairy men and women, and typhoid stools are mixed with 
the water which is used for washing utensils. 

Now, what is it that boiling can and will do? Besides ex- 
pelling air, it destroys the germs of typhoid fever, Asiatic 
cholera, diphtheria, and tuberculosis, also the oidium lactis, 
which is the cause of the change of milk-sugar into lactic acid 
and of the rapid acidulation of milk with its bad effects on 
the secretion of the intestinal tract. Some varieties of pro- 
teus and most of bacterium coli are also rendered innocuous 
by boiling. Thus it prevents many cases of infant diarrhoea 
and vomiting, but not all of them, for the most dangerous 
bacteria are influenced neither by plain boiling nor by the 
common methods of sterilization. Besides, "diarrhoea" is but 
a symptom of many causes, and "cholera infantum" is a name 
for a condition occasioned by many. Ebstein emphasizes the 



* P. 18. "After boiling, milk destined for the use of a baby during 
the day should be kept in clean bottles containing from three to six 
ounces, filled up to the cork, and the bottles then turned upsidedown 
in a cold place ; such will keep longer than milk preserved in the usual 
way. Before being used it should be heated in a water-bath; and by 
repeating this heating of the whole amount of the day's milk several 
times during the twenty-four hours, fermentation will be retarded and 
digestibility improved." 



24 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

fact that babies at the breast are subject to cholera infantum, 
particularly in southern climates, also in public institutions. 
The influence of external temperature is a very important 
factor; its sudden changes produce intestinal disorders. Babies 
taken from a hot railroad car to the deck of a lake steamer, 
from a warm bed to a draughty room, may develop a catarrhal 
enteritis which disposes to worse forms of disease, for the mor- 
bid condition of the epithelium caused by such sudden changes 
is a proximate cause of disease because it opens the way to all 
sorts of infecting substances. Poisons in the food of cows, in- 
digestible baby foods, — either indigestible per se or through 
a morbid condition of the digestive organs, — produce diarrhoea 
of many varieties. It need not even depend on ingested food, 
for, according to W. Schild's recent investigations (Zeitsch. f. 
Hyg. u. Infect., xix.), germs of diseases may be found in the 
intestine of the newly-born in from ten to seventeen hours 
after birth (minimum four, maximum twenty). The meco- 
nium of the newly-born, being free of germs, is supplied 
through the mouth with the bacterium coli, and through the 
anus with the bacillus fluorescens, subtilis, and proteus. Even 
adults are infected through the same inlet. Linen, the bath, 
the air, the blood are sources of local invasion. In such cases 
what is the sterilization of artificial food to accomplish? They 
are not reached by it. 

Not even the natural food, breast-milk, is free of germs pos- 
sibly attended by dangers. M. Cohn and H. Neumann found 
germs in the healthy breast-milk, even after the mamma and 
nipples had been washed with alcohol and with solutions of cor- 
rosive sublimate. A. Palleske met with the staphylococcus 
pyogenes albus in one half of all healthy women, F. Honig- 
mann {Zeitsch. f. Hyg. u. Infect., xiv.) in most of them, and 
H. Knochenstein (Inaug. Diss., 1893) in the mammae of eight 
puerperal and nursing women. He thinks they had immi- 
grated from outside; they proved innocuous. But who can 
doubt that if the epithelium of the milk-ducts had been mor- 



FEUDING OF SICK CHILDREN. 25 

bid, there would have been a chance for mastitis, or if the 
staphylococcic milk had come in contact with a sore stomach 
or intestine, there would have been an opportunity for gastritis 
or enteritis? Many more observers have come to the same con- 
clusions. Several species of cocci, particularly staphylococcus 
pyogenes albus, are found in most (perhaps in all?) specimens 
of the milk of healthy women. In that of sick women many 
more bacteria may be met with, for instance, streptococcus 
albus, streptococcus pyogenes aureus (in mastitis by Cohn and 
Neumann), coccus pneumoniae (in pneumonia of the mother by 
Foa and others). Puerperal women with fever had several 
bacteria in their milk (Escherich). Whether such milks are 
safe cannot yet be either asserted or denied. 

Nor is boiling, or sterilization, a safe protection under all 
circumstances. Aerobic bacteria, the so-called hay or potato 
bacilli, have very resistant spores, which develop in time. They 
are found in cow-dung and in the dust of stables, of the soil 
and streets, and of hay; they render the milk alkaline and 
bitter; they peptonize casein and liquefy it and make the milk 
still more bitter. They are very poisonous; their pure culture 
gives young dogs a fatal diarrhoea. It takes hours of steriliza- 
tion to kill them; in some instances it required five or six 
hours. Even the bacillus butyricus takes an hour and a half. 
But such a protracted sterilization, besides being far from cer- 
tain in its effect, is a clumsy procedure and one not calculated 
to benefit the milk. Thus, hay feeding is an absolute necessity, 
for the bacilli are destroyed by a six weeks' drying. Besides, 
it is important to keep the stables scrupulously clean, to avoid 
dirt and dust, to employ peat instead of straw for bedding, to 
wash the udder and tie the tails before milking, to throw away 
the first milk, and to remove foreign material from the milk 
by centrifuging. But no absolute security can be guaranteed. 
Therefore Fliigge adds to his expositions a warning against 
some wholesale manufacturers who, always anxious about some- 
body's — their own — welfare, were (are?) known to conceal the 



26 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

changed condition of the milk and the separation of butter 
particles by coloring the glass of their bottles. 

Whatever I have here brought forward is certainly not to 
disparage the boiling of the milk; it is meant to prove the 
danger of relying on a single preventive when the causes of 
intestinal disorders are so many. It is true, however, that the 
large majority of the latter depend on causes which may be 
met by sterilization, but not by sterilization only; also by 
pasteurization, — that is, heating the milk to 70° C. = 158° F., 
and keeping it at that temperature for thirty minutes, — a pro- 
cedure which destroys the same germs that are killed by a more 
elevated temperature without much change in the flavor and 
taste of the milk. 

One of the questions connected with the employment of 
sterilized or pasteurized milk is this, whether the milk to be 
used for a child ought to be prepared at home, or whether the 
supply may be procured from an establishment where large 
quantities of milk believed to become immutable for an indefi- 
nite period by sterilization are kept for sale. In regard to this 
problem, Flugge plaintively expresses his regrets that "we have 
allowed ourselves to be guided by people who are neither hy- 
gienists nor physicians, but chemists, farmers, or apothecaries, 
and whose actions have been based on three false beliefs. Of 
these the first is that boiling for three-quarters of an hour 
destroys germs, the second that whatever bacteria remain un- 
destroyed are innocuous, and the third that proliferating bac- 
teria can always be recognized by symptoms of decomposition." 
Nothing is more erroneous. Soxhlet himself, the German 
originator of sterilization, knew at an early period that the fer- 
menting process is now and then but partially interrupted by 
boiling, that butyric acid may be found in place of lactic acid, 
that a strong evolution of gas may be caused after such boiling, 
and that such milk may give rise to flatulency. Aye, milk 
which happens to contain the resistant spores of bacteria be- 
comes a better breeding-ground for them by the very elimina- 



FEEDING OF SICK CHILDREN. 27 

tion of lactic acid, and the longer such sterilized milk is pre- 
served and offered for sale the worse is its condition. It may 
be true that these conditions are not met with very frequently, 
but an occasional single death in a family caused by poisonous 
milk will be more than enough. Therefore, the daily home 
sterilization is by far preferable to the risky purchase from 
wholesome manufacturers who cannot guarantee because in the 
nature of things they cannot know the condition of their 
wares. 

Another alteration of a less dangerous character, but far 
from being desirable, is the separation of cream from sterilized 
milk which is preserved for sale. Renk (Arch. f. Hyg., xvii.) 
found that it took place to a slight extent during the first 
weeks, but later to such a degree that 43.5 per cent, of all the 
cream contained in the milk was eliminated. 

Sterilization has been claimed to be no unmixed boon be- 
cause of its changing the chemical constitution of milk. Still, 
opinions on that subject vary to a great extent, the occur- 
rence of changes being both asserted and denied by apparently 
competent judges. But what I have said a hundred times is 
still true and borne out by facts, — viz., that no matter how 
beneficial boiling, or sterilization, or pasteurization may be, it 
cannot transform cow's milk into woman's milk, and that it is 
a mistake to believe that the former, by mere sterilization, is a 
full substitute for the latter. It is true that when we cannot 
have woman's milk we cannot do without cow's milk. There 
is no alleged substitute that can be had with equal facility or 
in sufficient quantity. But after all it is not woman's milk. 
Babies may not succumb by using it, and may but seldom 
appear to suffer from it; indeed, they will mostly appear to 
thrive on it; but it is a makeshift after all and requires modi- 
fications. Hammarsten was the first to prove the chemical 
difference between the casein of cow's and woman's milk. 
"Whatever was known on this subject at that time I collated 
in Gerhardt's "Handb. d. Kind.," vol. i., 1875 (2d ed., 1882). 



28 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

The casein of woman's milk is not so easily thrown out by acids 
or salts as that 'of cow's milk, and is more readily dissolved in 
an excess of acid. But lately Wroblewski demonstrated the 
difference in solubility of the two milks. Woman's casein re- 
tains, during pepsin digestion, its nuclein (proteid rich in phos- 
phorus) in solution: it is fully digested; in cow's casein the 
nuclein is not fully digested: a "paranuclein" is deposited un- 
dissolved and undigested. Besides, woman's casein contains an 
additional albuminoid which is not identical with either the 
known casein or albumen. (H. Koplik in N. Y. Med. Journal, 
April 13, 1895.) Of the albuminoids in woman's milk sixty- 
three per cent, are casein, thirty-seven per cent, lacto-albumen 
(Schlossmann), which being directly absorbable constitutes an 
essential difference from cow's milk; all of the latter has to be 
transformed during the digestive process before it can be as- 
similated. Besides, there is (Wroblewski) in the human milk 
another proteid rich in sulphur, poor in hydrocarbon, and, ac- 
cording to several authors, albumoses and peptones. 

K. Wittmaack and M. Siegfried published lately (Zeitsch. f. 
phys. Chem., xxii.) their essays on the nucleon (the phosphoric 
acid of muscle) in the milks of cow, woman, and goat, and on 
phosphorus in the milks of the cow and the woman. Their 
conclusions are accepted by E. Salkowski as correct, which, I 
should say, proves them to be so. Cow's milk contains 0.057, 
goat's milk 0.110, and woman's milk 0.124 per cent, nucleon. 
In cow's milk the phosphorus of the nucleon amounts to six 
per cent, of the total amount of phosphorus contained in the 
milk; in woman's milk 41.5 per cent. That means that in 
cow's milk not one-half of its phosphorus is in the organic 
combinations of casein and nucleon; in woman's milk almost 
all of it. In cow's milk the phosphorus not utilized for or- 
ganic combinations is contained in the inferior phosphates. E. 
Salkowski adds the following remarks; "These conditions are 
evidently of the greatest moment in the nutrition of the 
nursling. As the development of bones is more readily ac- 



FEEDING OF SICK CHILDREN. 29 

complished in nurslings fed on woman's milk than in those 
fed on cow's milk, the probable conclusion is this: that nu- 
cleon has an important part in the absorption and assimilation 
of phosphorus. The same should be said of calcium, which 
also combines with nucleon. Though woman's milk contains 
less calcium than cow's milk, more calcium is utilized out of 
the former, and the nucleon is evidently an important factor 
in its absorption also." 

Ergo, cow's milk is not woman's milk. It is not identical 
with it. Sterilization does not change its character; it merely 
obviates such dangers as result from the presence of most 
pathogenic germs and from premature acidulation. The sub- 
stitution of cow's milk or of sterilized cow's milk for woman's 
milk as the exclusive infant food is a mistake. Experience 
teaches that digestive disorders, such as constipation or diar- 
rhoea, and constitutional derangements, such as rhachitis, are 
frequently produced by its persistent use, and it appears to 
be more than an occasional (at least co-operative) cause of 
scurvy. 

Since the advisability of finely dividing and suspending the 
casein of cow's milk and of adding to the nutritiousness of the 
latter caused me always to teach the admixture of cereals to it, 
even in the very first days of infancy, the subject of infant 
feeding has never been lost sight of by medical men, scientists, 
and tradesmen. No subject has been treated more extensively, 
more eagerly, sometimes even more spitefully, than that of 
infant feeding. The philosopher's stone has not been so 
anxiously sought for nor so often found in medical journals, 
books, and societies as the correct infant food and the appro- 
priate treatment of cow's milk. After the finally faultless 
thing had been discovered very many times, it was not a sur- 
prise but a source of gratification to me to meet, in the Berl. 
Min. Woch., No. 10, 1895, an article of Heubner's, who, after 
having contributed for years as much as any writer (if not 
more) to the literature of the subject, recommends the "utili- 



30 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

zation of flour in the intestines of young nurslings." Basing 
his remarks, first, on the researches of Schiffer, Korowin, and 
Zweifel (quoted in my early writings on that topic more than 
twenty years ago), who, by experimentally proving the digesti- 
bility of a certain amount of starch in the saliva (and pan- 
creatic juice) of young infants,* justified my empirical findings 
of many previous years, and, secondly, on what he is pleased to 
call "Jacobi's practical experience," the Berlin physician rec- 
ommends in intestinal diseases of the very young the simplest 
flours, mainly of rice and oats (which have a finer microscopical 
structure than wheat). He pointedly adds, "Very young in- 
fants do better on a dilution of milk with a thin rice decoction 
than with mere milk-sugar solution. Practical experience sur- 
passes theoretical conclusions."! There is but one point in 
which the famous teacher does not yet agree with me, for in his 
expositions we meet with the remark that he "cannot approve 
of the colossal dilution recommended by the authority of 
Jacobi." The "colossal dilution" alluded to is that of milk in 
four or five parts of oatmeal- or barley-water for the use of the 
newly-born. In regard to this dilution also I trust I shall yet 
see my illustrious colleague siding with me. The demands of 
pepsin digestion and of rapid growth and the necessity of 
restitution of losses experienced by eliminations and excre- 
tions are just so many reasons for extra allowances of water 
in the diet of very young infants, who have to rely on the 



* Bias dies hard. While it took Heubner more than twenty years to 
avail himself of very accessible physiological experience, a celebrity of 
equal rank (Philip Biedert, Handbuch der KinderlcranJcheiten, 11th ed., 
1894, p. 39) still appears to approve of the opinion that a nursling must 
have "no amylacea" because of their indigestibility, before the pro- 
trusion of teeth. Still, he advises cereals for the dilution of his cream 
mixture. Before long it will be a generally accepted axiom that cereals 
must be given to make teeth and tissues generally when milk food 
alone does not suffice for their development. 

t "Probiren geht iiber Studiren." 



FEEDING OF SICK CHILDREN. 31 

services of others. Older children know how to find it and 
how to serve themselves. In addition, it is certainly true that 
a large amount of water passing through the kidneys removes 
the inconveniences and dangers of the peculiar physiological 
process which takes place during the first three weeks of every 
life, — viz., uric acid infarction, — the results of which are 
gravel, renal calculus (by no means rare), and nephritis. In- 
deed, since the rather frequent adoption of my plan of supply- 
ing the very young with quantities of water, I hear less of renal 
complaints in them than I did dozens of years ago. 

Perhaps the tide is already beginning to turn in my direc- 
tion. Norbert Auerbach, whose researches on the difficulty 
of destroying the hay bacillus and the bacillus butyricus are 
very meritorious, recommends larger percentages of water in 
infant feeding than the customary ones. His mixtures for the 
first and second months of life are three parts of water and one 
of milk; for the third and fourth, two and one; for the fifth 
and sixth, one and one; for the seventh and eighth, one and 
two. His figures are, therefore, not exactly like mine, but even 
they may appear heretic to my critic. In connection with this 
subject I am also pleased to state that Auerbach agrees with 
me on another subject. The sugar he adds to the milk food of 
infants is not milk-sugar, but cane-sugar, of which he gives 
twenty grammes daily, and — also according to my old teaching 
— more during constipation. He undoubtedly prefers cane- 
sugar for the reasons which guided me in my recommendations, 
though it is true that milk-sugar is being stripped of its dan- 
gers in the same degree as boiling, sterilization, or pasteuriza- 
tion is carefully practised. 

Virtually, sterilization has been practised by me these more 
than forty years, and has been taught by me for thirty-five 
years, both in lectures and in books and essays. My method 
has been referred to. I always urged that safety increased 
with the number of boilings. Still, certain New York gen- 
tlemen have been pleased to say, even lately, and one of them 



32 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

has printed, though he was told of his mistake before printing, 
that Jaeobi was an opponent of sterilization. 

Actual sterilization, according to Soxhlet, was introduced in 
New York by A. Caille. Then manufacturing firms took it 
up as a matter of course. One of them was prevailed upon 
by me to execute a device of Dr. A. Seibert, who advised the 
determination of the amount of sterilized food and the grad- 
uation of the feeding-bottles according to the weight of the 
infant. In most cases this plan is good, for the condition of 
the child can mostly be measured by the increase of its weight. 
Only fat, clumsy, rhachitical children are exceptions; in them 
the rapid increase of weight is rather a morbid condition than 
a symptom of healthy development. Besides, he improved 
his food by adding, in conformity with my practice, and steril- 
izing at the same time with the milk, either barley- or oatmeal- 
water. A recommendation of his sterilizer is its cheapness, 
which makes it more accessible to the poor. Before being 
sterilized (pasteurized) milk ought to be filtered. Most cooks 
employ napkins for that purpose. Absorbent cotton answers 
as well. 

The writings and practical instruction of Dr. Eowland 
Godfrey Freeman have been a great advantage to New York, 
particularly to its poor population. He insists upon pasteur- 
ization as a sufficient method of safety. The apparatus devised 
by him is thoroughly appropriate. As the adviser of Mr. 
Nathan Strauss in his successful endeavors to supply thousands 
with a safe article of food, he has benefited the city and aided 
in setting an example which should and will be imitated. 

Pasteurization is also employed by Eotch. In a paper read 
before the American Pediatric Society at Boston, May 4, 1892,* 



* "The Value of Milk Laboratories for the Advancement of our 
Knowledge of Artificial Feeding," by T. M. Rotch, Archives of Pedi- 
atrics, February, 1893. Also "Pediatrics: The Hygienic and Medical 
Treatment of Children," Philadelphia, 1896, pp. 153-287. 



FEEDING OF SICK CHILDREN. 33 

he presented, among others, the following statements, which I 
gladly repeat, as I know his teachings to have done a great 
deal of good. Indeed, I was so much impressed by them that 
I encouraged the gentleman who had conducted a milk labora- 
tory on Dr. Rotch's plan in Boston to establish a similar insti- 
tution in New York. Northrup, Holt, and many others are ad- 
mirers of his teachings. Some of Dr. Botch's statements are 
as follows: 

"What the profession needs is the knowledge that they may 
have milk laboratories where the materials are clean, sterile, 
and exact in their percentages. Slight changes in the three 
elements of milk of which we have the most accurate knowl- 
edge — namely, fat, sugar, and albuminoids — are of real prac- 
tical value in managing the digestion and nutrition of the 
infant (normal percentage of fat, 2.02-4.37; of milk-sugar, 
5.70-7.10; of albuminoids, 1.08-3.07; of mineral matter, 
0.12-0.20). The digestive capabilities of infants differ just as 
do those of adults, and nature therefore provides a variety of 
good breast-milks adapted to the individual idiosyncrasy of 
the special infant. With this fact impressed upon us, we can 
well see that in artificial feeding no routine mixture will in all 
cases prove successful." 

All this proves also that nature allows a great deal of lati- 
tude, for the milk of a woman is changing, sometimes quite 
rapidly, and still the baby continues to thrive. It also proves 
that an attempt at regulating the percentages of milk according 
to invariable rules, while circumstances of surroundings and 
individual health — perceptibly changed or not — may differ, is 
liable to be very deceptive. Altogether, no iron-clad rule holds 
good for a living body in which organic assimilation is not 
regulated by the fixed laws of crystallization. This is, indeed, 
proved by nothing better than by the variability of the con- 
stituents of good milk. According to the very figures pre- 
sented by Dr. Rotch himself, fat may vary from 2.2 to 4.37, 

3 



34 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

albuminoids from 1.08 to 3.27, and still the milks exhibiting 
these wide differences are "normal."* 

In regard to the percentages of fat in cow's and in woman's 
milk, the results of chemical analysis have lately changed in 
favor of the latter. But the general principles in regard to fat 
feeding — its effect on digestion, and the normal occurrence of 
fat in the healthy fasces of an infant fed on normal nourish- 
ment (breast-milk) — are not thereby altered. 

Neither mathematics nor chemistry alone directs the organic 
economy. If that were so, the chemist Soxhlet, otherwise so 
deserving and justly famous, would be justified in the advice 
he coolly gives the physician to add milk-sugar when there is 
no fat in the food, and thereby to obtain the necessary amount 
of carbon hydrates. Fortunately, organic chemistry is not 
identical with physiology. 

The methods of Biedert and Arthur Meigs are based upon 
these modern analyses of milk. The former prepares a cream 
mixture which contains one per cent, of casein, two of fat, and 
four of sugar. It is to be mixed with milk in different propor- 
tions. One of the reasons urged by him for the addition of 
cream is the necessity of greater dilution (accomplished by 
my cereal decoctions) of the cow casein, the difficult digestion 
of which he takes for granted. 

In his "Kinderemahrung," 2d ed., pp. 152, 170, Biedert rec- 
ommends to feed a baby during the first few months as follows: 
Every kilogramme (two pounds) of the baby's weight is fur- 
nished two hundred grammes (six and a half ounces) of food 
which contains fifty of milk, one hundred of oatmeal-water, 

* "So high an estimate of the casein as this must always be due to 
error, the consequence of failure to separate the casein and sugar. There 
is reason to believe that the copper test for milk-sugar is not reliable 
when applied to milk analysis. This test is the one employed by most 
analysts to estimate the sugar, and there is good reason to believe it 
to be entirely unreliable for the analysis of milk." Arthur V. Meigs, 
"Feeding in Early Infancy," 1896, p. 6. 



FEEDING OF SICK CHILDREN. 35 

and eight of sugar. Heubner ("Sauglingsernahrung und Saug- 
lingsspitaler," 1897, p. 13) mixes one part of milk with one of 
a flour decoction (one teaspoonful to one-half pint) which con- 
tains 12.3 per cent, of milk-sugar. Of this mixture he gives 
six hundred grammes daily up to the fourth week, seven hun- 
dred and fifty to the seventh, nine hundred after the eighth, in 
from eight to six meals. 

The mixture of Dr. Meigs is well thought of by many physi- 
cians. In his own words, "There must be obtained a quart of 
good fresh milk, not too rich, and not poor; average milk is 
best; this is placed in a high pitcher or other vessel and is 
allowed to stand in a cool place for three hours. The upper 
half or pint is then poured off, care being taken not to shake 
the vessel, and this upper pint of weak cream is to be kept for 
the use of the infant. 

"There must also be made a solution of milk-sugar of the 
proportion of eighteen drachms to the pint of water. It ought 
to be kept in a fairly cool place; if it be sour it must not be 
used. 

"Three tablespoonfuls of each, the weak cream and the 
sugar-water, are then mixed with two tablespoonfuls of lime- 
water. They are then warmed for use in the feeding-bottle. 

"In the great majority of instances where it has been fairly 
tried, this food has proved very successful" (A. V. Meigs's 
"Feeding in Early Infancy," 1896, p. 7). 

This food of Meigs's seems to be too easily influenced by ir- 
regularities, and by accidents happening to what he calls cream 
while it is obtained, and to the milk-sugar solution, to be proof 
against frequent mistakes and failures and to become popular 
among the masses. 

Dr. N". B. Coit, who believes that coVs milk when properly 
prepared furnishes the sufficient diet of an infant and supplies 
all its needs for robust health, gives the following rules for 
modified milk for infant feeding, made with one quart of bot- 
tled cow's milk: "First six months, the top milk, cream one-half 



36 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

pint, boiled water one pint, milk-sugar seven hundred grains; 
from six to nine months, the top milk, cream one pint, boiled 
water one pint, milk-sugar nine hundred grains; from nine 
months to one year, the top milk, cream one and one-half pints, 
boiled water one-half pint, white sugar three teaspoonfuls." 

Dr. Rotch continues, "We are in need of a means by which 
we can prescribe exactly according to the idiosyncrasy of the 
digestion we are dealing with. 

"A separator with many thousands of revolutions in a min- 
ute separates from the milk foreign material and divides it up 
into a cream of a stable percentage and separated milk. The 
milk-sugar and the albuminoids, also the mineral matter of 
this milk, are fairly well known, and thus the laboratory 
worker is enabled to put up any prescription, which, for a 
healthy baby of four months, would read: fat, 4 parts; milk- 
sugar, 7 parts; albuminoids, 1.50 parts. Put up eight tubes, 
each four ounces, with lime-water ten per cent. Pasteurize 
(75° C. = 167° F.) for twenty minutes. In this mixture the 
lime-water is just sufficient to slightly alkalinize the cow's 
milk.* In this way the food of the child can be modified ac- 
cording to age and to changed conditions of health." 

* Cow's milk is either alkaline, or neutral, or acid. The constant rec- 
ommendation of five per cent, of lime-water for the purpose of alkaliniza- 
tion is, therefore, far from exact and strictly scientific. Besides, how 
much alkalinization is effected by one and a half drachms of lime-water? 
They contain exactly, or are presumed to contain, one-eighth of a grain 
of lime. 

Lime-water (liquor calcis) is a saturated aqueous solution of calcium 
hydrate whose percentage varies with its temperature. At 59° F. it 
contains somewhat over 0.17 per cent., in rising temperature less, at 
the boiling-point one part of lime in thirteen hundred of water. It re- 
dissolves as the liquid cools. If the food containing lime-water be given 
at a temperature of eighty or ninety degrees, part of the lime is thrown 
out. Lime-water warmed loses most of its alkaline reaction; it is 
markedly alkaline when cold, only faintly so when boiled. An experi- 
ment made with good milk from the household supply gave the follow- 
ing results: Keaction acid, also on boiling. One- twentieth part of lime- 



FEEDING OF SICK CHILDREN. 37 

In a case of duodenal jaundice in a girl of six years, the doc- 
tor prescribed fat, 0.5 part; milk-sugar, 6 parts; albuminoids, 

4 parts. Give four ounces every two hours. Send twelve tubes, 
each four ounces, lime-water ten per cent. In a case of sum- 
mer diarrhoea in a girl of four months, fat, 2 parts; milk-sugar, 

5 parts; albuminoids, 1 part. Send twenty tubes, each one 
ounce and one drachm. At time of each feeding add lime- 
water, three drachms. Sterilize at 212° F. 

One of the beliefs guiding the author of this method is as 
follows: "The constituents of the nutriment which nature has 
provided for the offspring of all animals and human beings 
that suckle their young are essentially animal, and not vege- 
table. Human beings in the first twelve months of life are 
carnivora. An animal food entirely and always free from any 
vegetable constituents has been proved to be the nutriment on 
which the greatest number of human beings live and the least 
number die." 

Those who have followed my teachings at any time during 
the last third of a century know that I take some exception 
to this broad statement. Saliva and pancreatic juice are good 
for something better than idle elimination, and "nature" pre- 
pared the animal young from the first moment for more than 
mere pepsin digestion. The proof Dr. Eotch refers to is his 
experience only. Mine has taught me somewhat differently 
from the axiomatic positiveness of his assertion. But be it 
far from me not to present Dr. Botch's case in full. His stand- 
ing and merits are such as to give him a hearing wherever and 

water added to it changed the reaction but slightly: it remained acid. 
The mixture being boiled, reaction remained the same. When again 
cooled and shaken up it was still acid, but slightly less so than before 
the dilution of the milk with lime-water. 

The addition of bicarbonate of sodium to milk which is to be kept 
from souring, a procedure which is (besides lime-water) recommended 
by Holt also, may become a grave mistake. The very bacilli which, 
with their spores, resist boiling to an unusual degree, thrive best in 
a milk that is made thoroughly alkaline. 



38 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

whatever he discusses. His rules, which, moreover, may be 
modified by my method at any time, are thoroughly good; they 
are scientific., exact, and well thought out. Moreover, they 
have been proved to be practicable. No matter whether it is 
the careful handling of a cautiously prepared milk, the 
methodical composition according to percentages, or the faith- 
ful pasteurization, or all of them, the results are good. I know 
of a number of babies who in health and disease have done well 
on the protracted use of the laboratory milk. Only one obser- 
vation struck me in many cases. The formation of the muscles, 
and particularly of the bones, appeared to be slow; the teeth 
came a number of weeks or even months too late; the cranial 
bones turned slightly soft in not a few instances. In many such 
cases I had to add animal broths or juice before the usual time; 
in two, when I tried phosphorus (elixir phosphori), it was re- 
jected; in all others it was well borne and useful. But, taken 
all in all, the method appears to be sound and successful, so 
far as it can be with cow's milk and the casein of cow's milk. 
It is to be deplored that for the present it is a method only ac- 
cessible to the rich; it required a special benevolent fund to 
supply one hundred and twenty-five Boston poor children with 
the same food; mine has the advantage of being one for the 
people, both rich and poor. If, or as long as, the circulars of 
the laboratory keep free of pretentious exaggerations, — there 
was a time when they took that turn, — the profession will do 
well to rely on it, or its like, as one of the means of furnishing 
the baby a food deprived of dangers and in most cases suffi- 
cient. When it is found insufficient as regards tissue-building, 
cereals may always be furnished in the same mixture. The 
empirical knowledge of their beneficial effects with which we 
have been furnished for more than a generation has lately 
again been tested experimentally by Springer, of Paris, who 
improves the development of bone by a decoction of mixed 
cereals boiled for hours in succession. This long duration of 
the boiling process is, however, not demanded. 



FEEDING OF SICK CHILDREN. 39 

Like Professor Kotch, Professor G. Gaertner,* of Vienna, 
employs the centrifuge f for the purpose of obtaining a milk 
resembling that of woman. The latter was found by Escherich 
to contain casein 1.82, fat 3.10, and sugar 6.23 per cent. The 
average of many examinations of cow's milk resulted in casein 
3.76, fat 1.81, and sugar 2.1 per cent. That of "fat milk"' con- 
tained casein 1.76, fat 3, and sugar 2.1 per cent. This "fat 
milk" is obtained by so arranging the tube which expels the 
cream from the centrifuge separator that just one-half of the 
milk contained therein is expelled and collected. In this way, 
as casein, sugar, and minerals are not affected by the process 
of centrifuging, their percentages are not changed, while that 
of the fat is doubled. The difference between Gaertner's and 
Botch's methods is this: that the former is applicable to the 
large majority (but that only) of infants who require cow's 
milk appropriately prepared; and that the latter permits of 
all sorts of changes and percentages, and of all adaptations to 
the requirements of both the well and the sick, according to 
the opinions and intentions of the physician in every individual 
case. Gaertner's milk is to be given in the same unchanged 
percentages during all the months of feeding; only the quanti- 
ties are gradually increased and the number of meals is dimin- 
ished. He does not consider the fact that woman's milk (not to 
speak of colostrum) contains more albumin and salts and less 
fat in the first few months, but less albumin and salts and more 
fat later. What little experience I had with it, however, during 
a few short months seems to be favorable. But what I said of 
many cases fed on Botch's modified milk will, I fear, occur 
here. There will be lack of tissue building, and close watching 



*Ueber die Herstellunor der Fettmilch, VVien. 1S94. Professor Esch- 
erich, Die Gaertner'sche Fettmilch. eine nene Methode der Siiuglingser- 
nahrung. Both in Wiener Med. YToch.. 1S94. 

t Recommended for the preparation of children's milk in my Cf Intes- 
tinal Diseases," 1SS7, p. 23. 



40 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

and additional feeding and medication may be required in 
many instances. 

Another difference between the two is almost self-under- 
stood, and explained by the tone and the usages of the medical 
profession in some parts of Europe. The Gaertner milk is 
patented by the inventor and sent to the market with semi- 
scientific, partly unintelligible, and rather boastful circulars. 
(Per contra, Biedert, whose cream mixture is also in the market, 
has no personal patent and derives no pecuniary advantage 
from his procedure.) 

Practitioners and authors who convince themselves of the ill 
success often attending the use of milk, or watered milk, com- 
menced at an early period to mix it with MEAT-soups, meat-tea, 
or egg. Bretonneau reported, as early as 1818, that "tabes 
mesenterica" disappeared, in the hospital of Tours, from 
among the children fed on beef-soup and milk. This mixture 
Vauquelin declared to come nearest to mother's milk of all 
preparations. The administration of some beef-soup, well 
made, a cupful every day (mutton-broth when there is a ten- 
dency to diarrhoea), is advisable towards the end of the first 
year. Long before this period, indeed at any time during in- 
fancy, it is indicated in cases of early rhachitis, though there be 
but few symptoms such as rhachitical constipation, undue adi- 
posity, or retarded teething. 

Beef -tea, well made, in a bottle swimming in the water-bath, 
is still believed by some to be the model food. That it is not 
so rich in soluble albuminoids as was believed, ought to be 
generally understood by this time. What, however, it does 
contain in large quantities is salts. Thus it is a dangerous 
article in summer diarrhoea, and must never be administered 
by itself. When given at all, it ought to be in combination 
with farinacea, raw albumin (which in this mixture requires 
very little salt, if any). 

Beef -broth, as far as albuminoids are concerned, is about as 
nutritious as whey, and no more. But on account of the ex- 



FEEDING OF SICK CHILDREN. 41 

tractive substances of beef, kreatin and kreatinin, it is more 
stimulating. The temperature of the body is not raised by it. 
In gastric irritation, gastritis, and acute dysentery it ought not 
to be given. Veal-broth is liable to increase diarrhoea, mutton- 
broth constipation, and the latter is therefore preferable in 
cases of diarrhoea. A broth of beef, which contains from 1.5 
to 2 per cent, of albumin, is made by mixing one part of beef 
and six of water with a little chloride of sodium and allowing 
it to stand from ten to twelve hours. Then it is slowly boiled 
and the whole mass pressed out. Still better is a modification 
of Liebig's beef-tea, which is obtained by adding one half-pint 
of water, with six or seven drops of dilute muriatic acid, to a 
quarter or one-half of a pound of finely-cut lean beef, stirring 
it occasionally during two hours, and boiling a few minutes. 
Beef-juice obtained by pressing out beef after slightly broiling 
it, contains from six to seven per cent, of albumin. It is 
slightly acid, and spoils quickly. 

The peptonized beef preparations are available both inter- 
nally and for rectal alimentation. They may be mixed with 
hot water or hot broth; a few teaspoonfuls and upwaid are 
valuable additions to the daily food. Those who object to some 
of them, because of their strong aromatic taste and color, will 
still relish them when quite cold. Still, the administration of 
peptones should be controlled by a careful consideration of the 
condition of the digestive organs. The last product of gastric 
digestion is albumose; the formation of peptone is not com- 
pleted until the diastatic action of the pancreas, and perhaps 
also of some intestinal bacteria, has reached the chyme. It was 
taken for granted that neither albumose nor peptone could be 
formed without the presence of hydrochloric acid. In part this 
is a mistake, for dogs deprived of their stomachs, and men 
with no such secretion, are known to prepare them. Still pep- 
tones have been given for the purpose of supplying what the 
stomach could not, or was supposed not to be able to, furnish. 
It has a bitter taste, is not always well borne, even in the rec- 



42 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

turn, and may cause vomiting or purging. A teaspoonful of 
most of the peptone preparations holds from three to four 
grammes of albumin, a fair addition to the nutriment of a 
patient whose condition requires much, and much digestible 
food. Still, sight should not be lost of the condition of the. 
digestive mucous membrane. In conditions of fever, conges- 
tion, catarrh, etc., absorption is very slow; mainly peptone is 
not absorbed, dyspeptones are formed, and a severe form of 
autoinfection may be the result. 

Scraped beef, raw, has been highly recommended in the 
chronic stage of, and convalescence from, exhausting gastro- 
enteric catarrh these forty years. It is very digestible, and 
but for the danger of causing taenia mediocanellata, a valuable 
addition to our means of restoring health. White meats con- 
tain less fat, haemoglobin, and extractive material than beef. 
Sweetbread (thymus), 22 per cent, of albumin, 6 gelatin, but 
0.4 fat, 1.6 salts, and 70 water. 

Meat thoroughly dried in the water-bath, and finely pow- 
dered, also hard egg albumin in the same condition, are easily 
taken in milk; they are excellent additions to a patient's diet, 
at a somewhat advanced age (at and after three or four years). 

Egg has been utilized as an admixture to milk, or as its sub- 
stitute, in a great many ways. Both the yelk and the albumin 
have been so employed. The white of an egg, with a little salt 
and six ounces of water, well beaten and shaken, is a good mix- 
ture, which can take the place of infant food only temporarily, 
but is an invaluable make-shift in severe intestinal catarrh, or 
a permanent nutriment in the same, when added to other food. 

Falkland skims milk, and transforms it by means of pepsin. 
The process does not recommend itself to general use on ac- 
count of its circumstantiality. Eoberts heats milk to nearly a 
boiling-point, and treats it with liquor pancreatis and bicar- 
bonate of sodium. Fairchild's method of peptonizing milk is 
generally understood all over the country and is widely appre- 
ciated. J. Kudisch's method of improving cow's milk for the 



FEEDING OF SICK CHILDREN. 43 

use of children and adults, sick and well, particularly those who 
suffer from gastric catarrh and do not digest milk in its usual 
composition, consists in mixing twenty-five minims (half a 
teaspoonful) of dilute hydrochloric acid with a pint of water. 
Then a quart of milk is added. When this mixture is boiled 
but a few moments it keeps well, and is quite palatable and 
highly digestible. 

Somatose is one of the artificial preparations which deserves 
some credit, first, because of the absence of such nucleins as 
irritate the kidneys; second, because it is a genuine albu- 
mose, a teaspoonful of which contains as much albumin as 
is held in half an egg or three tablespoonfuls of milk. Thus, 
a number of teaspoonfuls, well diluted in water or in broth, 
or now and then in milk, may be given daily in cases of anae- 
mia, or slow convalescence, or in sickness. To recommend it 
as a regular food is "trade;" to add it to cow's milk so as to 
make it "resemble human milk" (Rieth) is sheer nonsense. 

G. Klemperer, who discussed the artificial nutriments of the 
trade lately (Berliner Tclin. Woch., 1897, No. 26), takes excep- 
tion to every one because of their uselessness in "almost" every 
case. He correctly states that the products of the trade are ex- 
pensive, are mostly inferior to their promises and claims, and 
under ordinary circumstances should not be substituted for the 
direct products of nature. That is exactly the position I have 
always taken in regard to artificial foods; but the practitioner, 
who deals both with commonplace and with exceptional cases, 
is glad now and then to fall back on some preparation which, 
while not requiring the normal process of digestion, may save 
life in a given case. There is no food which suits every 
stomach or every case in the well or in the sick, and the greater 
the facility of a wholesome change the better. That is why, 
now and then, the artificial farinaceous foods, in which amy- 
lum is more or less transformed into dextrin, are filling a gap 
in the rare cases in which milk, though ever so well prepared, 
or the cereals, like oatmeal or barley, are not tolerated. Of the 



44 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

artificial foods extract of malt, which, with its albuminoids, 
fifty-three per cent, of sugar and fifteen of dextrin, is so nutri- 
tious that a tablespoonful is the equivalent of an egg, may be 
very serviceable. The percentage of sugar it contains is very 
nutritious; in the same way the effect of sugar (cane- and 
milk-), also of honey, ought to be utilized oftener than it seems 
to be usual. The hydrocarbons, generally, are the main food 
for the feeble and the feverish. Even the well will get along, 
for a time, with less albumin than was claimed by Liebig and 
by Voit, provided they are supplied with non-nitrogenous food. 
Under these conditions Hirschfeld limits the quantity of albu- 
min demanded by an adult to thirty or forty grammes (one to 
one and a half ounces). 

Alcohol has conquered its place among the medicinal foods 
in the diseases of infancy and childhood. Very little, if any, 
is required in catarrhal, or the first stages of inflammatory, 
diseases. It is contraindicated in meningitis, acute cardiac 
ailments, gastro-enteritis, peritonitis, and acute dysentery. It 
finds its application in depressed strength and vitality; thus, 
in the rules for the management of infants during the hottest 
(the very hot only) days of summer, distributed by the Health 
Department of the city of New York, I recommended the ad- 
ministration of a teaspoonful of whiskey daily. It is also re- 
quired in chronic diseases and slow convalescence. 

Its action is stimulant, nutritive, antipyretic, and antiseptic. 
It is decomposed into carbonic acid and water, and thus saves 
the waste of material parts of the body. When its odor is per- 
ceptible in the breath of the patient, it ought to be stopped or 
diminished. That is very liable to occur, for instance, in pneu- 
monia, in the first stage of which alcohol is but rarely indicated, 
or tolerated. When given in sufficient quantities, it reduces the 
temperature; the amount required for that purpose is, accord- 
ing to Binz, forty grammes, corresponding with about three 
ounces of brandy or whiskey. Its most beneficial action is 
exhibited in sepsis of all forms, mainly also in the septic varie- 



FEEDING OF SICK CHILDREN. 45 

ties of erysipelas, no matter whether there are brain symptoms 
or not, and of diphtheria. Here it is almost impossible to give 
too much. The doses must be watched so as to be sufficiently 
large. Whoever is not afraid of giving, in diphtheria, six 
ounces of whiskey daily to a child when one or two fail, or ten 
or twelve when six fail, will soon convince himself of its power 
for good. It must never be given in concentration; the gastric 
mucous membrane tolerates no pure brandy or whiskey for any 
length of time; they must be diluted with either water or milk 
properly prepared. Wines, brandies, and whiskeys are not 
equivalent. In our country the latter is obtained pure with 
greater facility, and at less expense, and besides has, for many, 
a less disagreeable taste than either of the others, which are 
often adulterated. The ether contained in wines militates 
against any antifebrile effect which may be expected from it; 
the fusel oil, also the furfurol (or pyromucic aldehyde), and the 
salicylic aldehyde, which is used in the manufacture of bitters, 
and the artificial bouquets, with which brandies are too fre- 
quently adulterated, act rather as paralyzing than as stimu- 
lating agents. 

Dyspepsia is one of the functional disorders of the stomach, 
and depends sometimes upon slight changes in the gastric mu- 
cous membrane. It consists in partial or complete loss of ap- 
petite, with more or less impaired digestion. In regard to this, 
however, in every individual case, it is good not to rely too. 
implicitly upon the reports of mothers or nurses. Older chil- 
dren will complain of prascordial heaviness. They will suffer, 
as do infants also, from eructations, which, when they result 
from swallowing air, are absolutely odorless, but when they 
consist of actual gastric gases, have a very faint odor. A sen- 
sation of oppression and frontal pain is complained of by older 
children; the younger ones are apt to vomit. 

The causes of dyspepsia must be sought for either in ana- 
tomical changes in the organ, which can rarely be proved; or 
(more frequently) in quantitative or qualitative changes in the 



46 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

secretion; or in a changed nervous influence, as, for instance, 
in fever; or in an abnormal condition of the food, which is 
the most frequent cause. 

The treatment of this disorder consists chiefly in abstinence 
or in the use of the greatest care in the preparation of meals. 
Milk requires boiling, peptonizing, or treating with muriatic 
acid according to the method I have detailed before. In every 
case the admixture of farinaceous decoctions and a little salt 
improves the digestibility of milk though prepared as de- 
scribed. In many the latter alone, with or without a meat 
soup, will be the only food which is tolerated. The gastric 
secretion of infants who have been fed artificially, is liable to 
be hyperacid. Alkalies should be given at once. The addi- 
tion of a few grains of bicarbonate of sodium (baking-powder) 
to the food may suffice. A few grains of an alkali (magnesia, 
sodium, calcium, according to the indications explained else- 
where), given a few minutes before every meal, act more surely. 

Vomiting has been mentioned among the symptoms which 
accompany dyspepsia. In the infant, however, it is almost a 
normal occurrence. The infantile stomach is vertical and 
more or less cylindrical, and the fundus but little developed. 
Thus, whenever there is a tendency to empty the stomach the 
antiperistaltic motions do not press against the fundus, but 
directly upward. There is, therefore, less genuine vomiting 
than a mere overflow of the contents, which mostly takes place 
so easily that the babies are not disturbed by it. 

The treatment of such cases, if treatment be required at all, 
would consist in the application of some dietetic rules. The 
infant should have less food, and at longer intervals; should 
not be carried about immediately after meals; ought not to be 
shaken or jolted; nor carried face downward. 

This overflow takes place, as a rule, immediately after the 
baby has been nursed; at that time the milk is still fluid. If 
vomiting occur a little later, the milk will be coagulated; if, 
then, the milk be not coagulated, the stomach is not in a nor- 



FEEDING OF SICK CHILDREN. 47 

mal condition. In these cases, and particularly when the baby 
lives on artificial food, there is uneasiness and pain associated 
with the vomiting. An acid mucus is expelled, together with 
the contents of the stomach; these are the cases in which anti- 
fermentatives, such as nitrate of silver, bismuth, resorcin, are 
indicated. Sometimes antacids alone will suffice, as detailed 
before. 

Gastkitis (Acute Gastric Catarrh). — The feeble, the 
anaemic, the convalescent, and the feverish are predisposed to 
this affection. But it may occur in the previously healthy as 
well. In all such children the production of normal gastric 
acid is diminished. Besides, in all of them, the muscular power 
of the stomach is reduced. 

Cold or hot ingesta, too large quantities of food, acids, spices, 
irritant medicines, alcoholic drinks, fat meat, cake, decom- 
posed food with its ferment, each may be the cause of acute 
gastric catarrh, and must be carefully avoided; dentition, as 
such, is not a cause. Exposure to changes or temperature is 
apt to produce gastritis, but the usual cause is improper food. 
A single small meal, consisting of, in that case, indigestible 
food, increases pain, vomiting, and fever. Abstinence and cold 
water to the head act well when there is a tendency to convul- 
sions. Cold applications to the heart will also reduce the tem- 
perature of the whole body. A warm bath will frequently do 
good; but bathing and handling the child should proceed with 
great caution and very gently while a convulsion is lasting. 
When thirst is very great, small quantities of ice-water should 
be given often, or seltzer-water, or Vichy, or Apollinaris; also 
water to which dilute muriatic acid has been added in the pro- 
portion of one to three or ten thousand. 

Solid food must not be taken. When there is a great deal 
of mucus, milk should be given, if at all, very much diluted, or 
prepared after Budisch's method. 

When the tendency to vomit is great, food and drink must 
be given in teaspoonful doses, and, when the sensitiveness of 



48 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

the stomach is very marked, mucilaginous and farinaceous 
foods only will answer, together with small doses of bismuth 
repeated every one or two hours. 

Where acid is predominant, calcined magnesium will answer 
best, if given in small doses frequently repeated; also bicar- 
bonate of sodium, and very small doses of opium, one-sixtieth 
to one hundred and fiftieth of a grain, every hour or two hours. 

Chronic Gastric Catarrh is either the termination of an 
acute catarrh, or of the persistent continuation of injurious in- 
fluences. Large and frequent meals, too cold or too hot food, 
and fast eating are frequent causes. The stomach may be 
either in a hyperaemic or in an anaemic condition; it may be 
hypersesthetic or atonic. Its secretion may be faulty or defi- 
cient. All of these changes may take place in the stomach 
without any complication on the part of neighboring organs, 
or these may be the only, or partial, causes of the gastric dis- 
order; thus pre-eminently cardiac or pulmonary ailments, 
which result in impaired circulation of the distant organs. In- 
deed, many a chronic catarrh of the stomach, both in the young 
and adult, requires among its first indications a proper atten- 
tion to the original cause. At all events, the number of meals 
and amount of food must be adapted to the digestive powers. 
Medication can do good service in most cases, either such as is 
directed to the mucous membrane itself (alkalies, bismuth), or 
to its faulty secretion (pepsin with muriatic acid, resorcin), or 
to the debilitated condition of its muscular power (strychnia). 
At all events, the children must be taught to eat slowly. Their 
food must be tepid, and not too much diluted, inasmuch as ab- 
sorption in many cases is slow. Sugar, fat, and starch must be 
allowed in small quantities only. 

Ulcerations of the stomach (and duodenum) demand that 
the organs should be kept as alkaline as possible. Abnormal 
acids (acetic, butyric, caprylic, or lactic in excess) must be 
neutralized before food is given. An occasional antacid is not 
sufficient to obtain that end; it must be given regularly, every 



FEEDING OF SICK CHILDEEX. 49 

two or three hours, also a few minutes before a meal. Sodium 
and magnesium salts, which contain carbonic acid, must not 
be given regularly. That gas produces peristalsis. Calcined 
magnesia answers best in doses of one or two grains, adminis- 
tered every hour, or every two or three hours, in water which 
must not be too cold. Hot water is even better. More than 
that quantity is seldom tolerated because of its purgative effect 
(which, however, is very welcome, to a certain extent, in pa- 
tients with a tendency to constipation). When a larger quantity 
of antacids is required, carbonate or phosphate of calcium may 
be added to the magnesium, with or without the subnitrate or 
subcarbonate of bismuth. In such a condition the effect of 
lime-water is in part imaginary. If given for the purpose of 
neutralizing strong acids, it is a failure. That medicinal treat- 
ment must be continued through weeks or months. Without 
it I see no gastric or duodenal ulceration getting well, in spite 
of the most careful dietetic regulations. 

The very function of the diseased organ is a great danger. 
Both stomach and duodenum must be kept as idle as possible, 
and their labors made easy. ~No indigestible food must be 
given, no solid food permitted. Most cases in older children 
bear boiled milk (in some mixed with a little bicarbonate of 
sodium), strained oatmeal or barley gruel, rice or arrow-root 
water, and stale wheat-bread; a few, also, raw beef, scraped. 
Some tolerate nothing but boiled milk, or buttermilk. There 
are those who prefer koumiss, matzoon, peptonized milk, or 
that prepared with muriatic acid. Whatever they take must 
be swallowed slowly. Milk, when drank hastily, is liable to 
coagulate in big, hard lumps, and proves indigestible and in- 
jurious. The same milk, when taken by the mouthfuls, or 
from a spoon, will prove beneficial. The milk should be boiled 
in the morning, and heated over again several times during the 
day, or it should be sterilized. It must not be cold when 
taken, and may be mixed with a little table-salt. Many prefer, 
and tolerate best, the mixture of milk and cereal decoctions. 

4 



50 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Such must be the food for weeks and sometimes for months; 
the meals must be small and more numerous. Thus the pa- 
tients will get well, and thus only. 

Acute and Chronic Enteritis, Intestinal Catarrh, 
with diarrhoea as a prominent symptom, compare with acute 
and chronic gastritis in their mutual relation. Acute catarrh 
of some duration extends mostly over the whole intestine; its 
worst cases are also complicated with the same condition of the 
stomach. The most serious forms are those of "acute gastro- 
enteritis." In them the diet must be a very strict one. No 
raw milk, no boiled milk, no milk at all in any mixture, in bad 
cases. In the very worst cases total abstinence for from one to 
six hours, or much longer; afterwards, teaspoon doses of a mu- 
cilaginous or farinaceous decoction from time to time. A good 
preparation is the following: Five ounces of barley-water, one 
or two drachms of brandy or whiskey, the white of one egg, 
salt, and cane-sugar; a teaspoonful every five or fifteen min- 
utes, according to age or case. Later on, a tablespoonful of 
boiled milk may be added. The same may be mixed with mut- 
ton-broth, which, with the white of egg, is better than beef- 
soup or beef-tea in convalescence. In vomiting, abstinence is 
mostly superior to ice; the latter may sometimes quiet the 
stomach, and feel pleasant momentarily, but it stimulates 
peristalsis. Beef-tea, in its customary preparation, ought to 
be avoided. In convalescence, when given at all, it ought to be 
mixed with barley- or rice-water. Towards the end of the dis- 
ease, or when the discharges are numerous and copious, the 
blood becomes inspissated, the circulation slow, and throm- 
boses (hydroencephaloid) form in the smallest veins of distant 
organs. Then it becomes necessary to introduce liquid into the 
circulation by administering water through the mouth or, if it 
tolerates it, the rectum; in desperate cases the infusion of a 
sterile salt-water solution (6 : 1000) into the subcutaneous tis- 
sue, once or repeatedly, may save life. Never is the common 
sense and tact of the intelligent practitioner more thoroughly 



FEEDING OF SICK CHILDREN. 51 

taxed. In regard to that there can be no law. No printed rule 
ever supplies or substitutes brains. 

In chronic cases boiled milk must form but a small part of 
the food. The white of eggs in water, or in barley- or rice- 
water, is superior. Still, there are exceptional cases in which 
even they are not tolerated. Then the cereal and farinaceous 
preparations, with or without mutton-broth, are preferable. In 
rare cases one of the better artificial foods is quite successful. 
Acorn coffee, acorn cocoa, answer well when given once or 
twice daily. The meals must be small, and may be more nu- 
merous, but a fair regularity must be kept up. 

Constipation may have many causes. The intestinal mu- 
cus may be deficient or too viscid. Such is the case in febrile 
conditions, now and then in chronic intestinal hyperemia, and 
also when there is too much perspiration and secretion of urine. 
Or the food may be inappropriate, as when it contains a super- 
abundance of casein, particularly in cow's milk, or of starch, 
or too few salts, or of sugar. 

Peristalsis may be incomplete through rhachitie debility of 
the muscular layer, or the muscular weakness dependent upon 
sedentary habits, chronic peritonitis, intestinal atrophy, and 
hydrocephalus. 

There is, also, besides mechanical obstruction by cystic 
tumors, intussusceptions, volvulus, and imperforations, an ap- 
parent constipation which ought not to be mistaken for any of 
the above varieties. Now and then a child will appear to be 
constipated, have a movement every two or three days, and at 
the same time the amount of fseces discharged is very small. 
This apparent constipation is seen in very young infants rather 
than in those of more advanced age. Such children are ema- 
ciated, sometimes atrophic. They appear to be constipated be- 
cause of lack of food, and not infrequently this apparent con- 
stipation is soon relieved by a sufficient amount of nutriment. 
Constipation resulting from a superabundance of starch in the 
food is easily cured by the withdrawal of the injurious sub- 
stance. 



52 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Constipation produced by too much casein in the food will 
be relieved by diminishing its quantity. The proportion of 
casein in the food of infants should never be more than one 
per cent. Besides, this amount of casein ought to be copiously 
mixed with a glutinous decoction (oatmeal). 

Infants that have been fed on starchy food, or even such 
cereals as barley, should have oatmeal substituted for it. 

Constipation depending on lack of sugar is very often 
speedily relieved by increasing the quantity of sugar in the 
food. This is the case not only in artificial feeding, but also 
when the children are fed normally on breast-milk. Such 
mother's milk as is white and dense, and contains a large 
amount of casein, is made more digestible, and will produce 
better evacuations, when a piece of loaf-sugar dissolved in tepid 
water, or in oatmeal-water, is given previously to every nursing. 
Older children will take honey to advantage, as long as it does 
not add to the abnormal gastric acids. Eegular doses of cod- 
liver oil, given twice or three times daily, will obviate or relieve 
constipation, besides fulfilling other indications. But it is self- 
understood that it must be pure, and not adulterated by the 
fashionable admixture of phosphate of calcium. Children of 
more advanced age, and with good gastric digestion, will be 
benefited by breads containing husk. Children of any age will 
be benefited by drinking large quantities of water. 

Ehachitis is sometimes the result of protracted intestinal 
disorders. Therefore proper feeding is an absolute necessity. 
Animal food must predominate, but meat ought to be lean. 
The so-called erethic rhachitis of thin, nervous children re- 
quires less meat, but more of the better class of farinaceous 
foods, — viz., barley, and oatmeal, with boiled milk, and salt. 
The same indications are valid for all the conditions subsumed 
under the head of scrofula. Coarse bread, acidulated food, fruit 
not absolutely ripe should be avoided. The introduction of 
phosphates, in whatever shape, is a mistake, for the following 
reasons: 



FEEDING OF SICK CHILDREN. 53 

In the careful experiments of Foster, who fed infants on 
milk, it was found that the mineral constituents were absorbed 
least (still less than fat). Of the ashes of milk in general, there 
were in the faeces 36.5 per cent.; of the calcium in particular, 
seventy-five per cent. In spite of that the baby throve, and in- 
creased in weight in one week one hundred and seventy 
grammes. Thus there appears to be but very little need of 
salts on the part of the growing baby. The infant of two and 
a half years receives in one day 1.25 grammes of calcium, of 
which there is an elimination of 0.92 gramme in the faeces and 
0.03 in the urine. There is then a balance of 0.3 gramme in 
a day, of 2.1 in a week, of a kilogramme, or two pounds of cal- 
cium, in a year. This is all that is utilized. 

Almost the entire quantity of calcium in the body is depos- 
ited in the bones, which contain eleven per cent, of calcium in 
the adult, and in the infant and child somewhat less. 

There are some very important practical points connected 
with the results of these observations. 

As long as the food contains plenty of calcium and phos- 
phoric acid there is certainly no indication for the introduction 
of the same in the form of medicine, or as an addition to food, 
for the purpose of improving nutrition. Thus the combination 
of cod-liver oil with phosphate of lime, which has become so 
fashionable, is based upon an illusion concerning its alleged 
efficiency. Besides, the empirical observation has been made 
also, at a very early time, that immediately after the adminis- 
tration of preparations of calcium there was increased elimina- 
tion through both the fasces and the urine. 

Thus, as there is no actual absence of calcium phosphate in 
the food, the organism should be spared useless labor. In 
occasional cases, where the effect appears to be favorable, this 
very effect is different from what was intended. When rha- 
chitical or anaemic infants are supplied with phosphate of lime, 
and iron, bismuth, etc., they are generally patients who are suf- 
fering from primary or secondary catarrh of the stomach, with 



54 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

superabundance of acid in its secretion. In these very cases 
the calcium phosphate acts as an antacid, inasmuch as phos- 
phoric acid becomes free and the lime neutralizes the acids of 
the digestive organs. 

Fever consumes nitrogen (elimination of urea), carbon, 
water, and also salts. These losses must be repaired, but with 
great care. For fever diminishes at the same time the secre- 
tion of saliva, and of gastric juice, probably also that of the 
pancreatic secretion. Besides, it renders the stomach hyper- 
Eesthetic (nausea, vomiting), and impairs the absorbing power 
of all the mucous membranes. In the capillary bronchitis of 
the nursling, cow's milk is not digested satisfactorily. Still, 
nurslings will digest fairly sometimes, and lose less flesh in 
many of their febrile ailments than older children. A small 
amount of peptones is absorbed both in the stomach and rec- 
tum. In moderate fevers some sugar is absorbed, also albumin; 
fat in but small quantities, because of its tendency to become 
acid; starch finds its saliva more or less diminished; thus its 
amount must be carefully estimated. 

Food, when given in an undue quantity, may act injuriously 
by acting as a mechanical irritation, and by giving rise to fer- 
mentation. Can it thus increase the fever? Undoubtedly. 
We see frequently children sick with pain and fever who re- 
cover rapidly through the effect of a purgative, which brings 
away large masses of faeces. Others have what appears to be a 
second relapse of typhoid fever, and often is but the result of 
intestinal autoinfection, with a renewal of splenic tumefaction. 
All the symptoms vanish speedily, in many instances when the 
bowels are thoroughly emptied of large offensive stools. 

In ordinary fevers the food must be liquid, and rather cool, 
in vomiting cold, in respiratory diseases warm, in collapse hot. 
The best feeding-time is the remission; in intermittent fevers 
nothing must be given during the attack except water, or acid- 
ulated water, now and then with an alcoholic stimulant; in 
septic fevers nothing during a chill, except either cold or hot 



FEEDING OF SICK CHILDREN. 55 

water, according to the wishes of the patient, with an alcoholic 
stimulant. Common ephemeral catarrhal fevers may do with- 
out food (except water) for a reasonable time. Sleep must not 
be disturbed, except in conditions of sepsis and depressed brain 
action. In both there is no sound sleep, but sopor, which 
should be interrupted. In sepsis (diphtheria and other) this 
rousing from sopor is an absolute necessity. Unless they are 
roused frequently to be fed sufficiently, and stimulated freely, 
the patients will die. Besides, in most of the cases, the tem- 
peratures are not high, and there is no contraindication to feed- 
ing on that account. 

Chronic inflammatory fevers bear and require feeding as 
generous as it must be careful. Altogether, however, it re- 
quires the good judgment of a well-informed physician to take 
into account the possible influences of individual habits, and 
energies, of ages and sexes, of constitutions, and of climate and 
season. 

Typhoid fever is of long duration, its temperature is some- 
times quite high in children, when of more advanced age. The 
small intestines are affected principally. Thus, not only is, 
after the first few days, a fair amount of food required, but it 
must be so chosen as to be digestible in the stomach; its proper 
selection is the more important the more the latter organ is 
impaired by high temperatures. Besides plenty of water, or 
acidulated water (hydrochloric, no organic, acid), albuminoids 
are indicated. Milk and cereals (in decoctions, which must be 
strained) are the proper foods. The administration of stimu- 
lants, both as to quantity and to time, depends on the charac- 
ter of the individual case, and the power of resistance on the 
part of the patient, besides on the condition of the heart. 
Where the latter becomes feeble at an early period, besides 
heart-stimulants (digitalis, sparteine, caffeine, camphor), alco- 
holic stimulants are required. Diarrhoea demands (besides 
opium, naphthalin) albumin, rice-water, arrow-root, mutton- 
broth. Hemorrhage, which fortunately is very rare in children, 



56 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

forbids food in any shape for a time, the duration of which 
depends on the general condition of the patient. At no time 
during the disease, and during the first ten days of fully estab- 
lished convalescence, should the food ever be solid. No veg- 
etables must be allowed until three weeks have elapsed since 
the beginning of apyrexia. When milk and cereal food be- 
come distasteful, a change in their preparation, as described 
above, are indicated. During most of the time broths of mut- 
ton, beef, or chicken, may also be given, or beef-juice or pep- 
tones diluted in water or in broths. The large majority of 
relapses are due to a dereliction in the strict rules of feeding. 

The diet in other chronic or acute diseases is regulated by 
the general rules which have been laid down before. Thus, a 
few words may suffice. 

Hereditary syphilis contraindicates the employment of 
a wet-nurse. The infant's own mother may nurse it if she 
can. 

Cerebral diseases contraindicate alcohol, coffee, hot soups, 
and solid foods. Cerebro-spinal meningitis results in speedy 
loss of weight and strength, particularly through severe and 
protracted vomiting, and the greatly-impaired appetite. In 
these cases feeding must be insisted upon. The feeding-cup, 
Soltmann's biberon pompe, and feeding through the nose 
(usually no tube into the oesophagus when there is much vomit- 
ing) must be resorted to. 

Eespiratory diseases require liquid food. Jurgensen's 
recommendation of roast, and bread with butter, is objection- 
able in every acute inflammatory case. Food and drink must 
not be too cold. Sugar, and sweets in general, are permissible 
in small quantities only. Farinaceous foods are the most re- 
liable ones. In the beginning no alcoholic stimulants. They 
will be required when debility and collapse set in at an early 
time, or in protracted cases. Capillary bronchitis is often com- 
plicated with gastro-enteritis, and then no milk can be allowed; 
sometimes not even breast-milk is digested. 



FEEDING OF SICK CHILDREN. 57 

Acute renal diseases contraindicate alcohol in any shape, 
particularly beer; also spices, coffee, and tea. Chronic benal 
diseases require generous feeding, because of the copious loss 
of albumin. But — contrary to Oertel and Loewenmayer — no 
eggs or meats ought to be given in any quantity, or at an early 
period. Milk and farinacea must take their places. Alcohol, 
as a stimulant, is permissible in urgent cases only. Salt must 
be avoided except when the secretion of urine is to be fostered. 
It ought not to be forgotten that appetite and digestion may 
be suffering from the fact that the tissue of the stomach is 
cedematous, like all the rest of the organs. This is another 
reason why eggs and meats ought to be avoided. If re- 
quired, in the later stages, peptones may take their place, but 
in small quantities only. Albumoses, such as somatose, are a 
good addition to the food, easily borne and readily absorbed. 
Milk in any shape and preparation is the main article of diet. 
It has no such nuclein as favors the formation of uric acid, 
and no extractive matters which contraindicate the use of meat 
in diseases of the kidneys. 

Acute rheumatism requires milk (also farinaceous) diet and 
vegetable acids (lemonade), the latter as long and at such times 
as they do not interfere with the milk food. 

RECTAL ALIMENTATION. 

The rectum absorbs, but it does not digest. Whatever, 
therefore, is to enter the circulation through the lower end of 
the alimentary canal must be dissolved before being injected. 
Suspension alone does not usually suffice. Water can be intro- 
duced in quantities of from twenty-five to one hundred 
grammes (one to three ounces) every one, two, or three hours, 
and may thus save life by adding to the contents of the thirsty 
lymph-ducts and empty blood-vessels. Salts in a mild solution, 
with cane-sugar, which is transformed into grape-sugar, and 
emulsionized fat, will thus be absorbed. Food must be more 
or less peptonized before being injected. Albumoses (for in- 



58 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

stance, "somatose") are readily absorbed in the rectum, so are 
also the peptones mentioned above when fairly diluted. When 
too thick they are not absorbed, become putrid, and a source 
of irritation. Milk ought to be peptonized. The white of one 
egg becomes absorbable through the addition of one gramme 
of chloride of sodium. Kussmaul beats two or three eggs with 
water, keeps the mixture through twelve hours, and injects it 
with some starch decoction. The latter is partly changed into 
dextrin. Fat, when mixed with alcohol, becomes apt to be 
partly absorbed. Andrew H. Smith recommends the injection 
of blood. Its soluble albumin, salts, and water are readily ab- 
sorbed; more we ought not to expect. Still, he has observed 
that the evacuations of the next day contained none of the in- 
jected blood. Whatever we do, however, and be the rectum 
ever so tolerant, not more than one-fourth part of the nutri- 
ment required for sustaining life can be obtained by rectal in- 
jections, and inanition will follow, though it be greatly delayed. 
Finally, children are not so favorably situated in regard to 
nutritious enemata as adults. In these the lengthening of the 
nozzle of the syringe by means of an elastic catheter permits of 
the introduction of a large quantity of liquid; indeed, a pint 
can be injected, and will be retained. But the great normal 
length of the sigmoid flexure in the infant and child, which 
results in its being bent upon itself, prevents the introduction 
of an instrument to a considerable height. It will bend upon 
itself; besides, a large amount will not be retained by the 
feeble or resisting young patient. The amount can be some- 
what increased by raising the baby by his feet, while the chest 
and abdomen are supported by a soft pillow, and by injecting 
quite slowly, or, rather, allowing the liquid to flow in from 
above downward. While the procedure is going on, the ab- 
domen should be gently manipulated. When a solid instru- 
ment is used, it is apt to be felt high up in the abdomen. This 
is the result of a large portion of the intestine being pushed 
upward with the tube. 



FEEDING OF SICK CHILDREN. 59 

The ingenuity of the practitioner will sometimes be severely 
taxed in regard to the choice of the mixture to be injected. 
Boas recommends for an adult two hundred and fifty cubic 
centimetres (eight ounces) of milk, the yelks of two eggs, a 
gramme of table-salt, a tablespoonful of claret, and a table- 
spoonful of diastased farinaceous food; Dujardin-Beaumetz, 
one glass of milk, the yelk of one egg, two or three table- 
spoonfuls of liquid peptone, five drops of laudanum, and one 
gramme of bicarbonate of sodium. The injections ought not 
to be too watery, and of the temperature of the body. When 
the rectum is very sensitive, the addition of a mild opiate is 
advisable at all events; sugar, alcohol, and whatever is apt to 
irritate the rectum, should not be given in large quantities. 
Straining, abdominal pressure generally, may be overcome by 
supporting the perineum and compressing the sphincter. (See 
also p. 71.) 

FORCIBLE FEEDING. 

When children or infants refuse, or are unable, to take food, 
forcible feeding should be resorted to. A proper amount of 
liquid food, from one-half of a pint to a pint or more, according 
to age, or to circumstances, should be introduced into the 
stomach by means of a sound of proper size several times a day. 
The procedure need not last longer than a few minutes, and the 
tube drawn out quickly so as not to irritate the pharynx. 

Nasal feeding is best accomplished through a small funnel 
which, to avoid pain, terminates in a short piece of India-rub- 
ber tubing. This is introduced into the larger nostril, the 
patient is held firmly on his back, and just enough food is 
poured in to allow the child to swallow. A small syringe, from 
which the piston has been withdrawn, may take the place of the 
funnel. 



II. 

GENERAL THERAPEUTICS. 

Thekapeutics of infants and children has enjoyed, or suf- 
fered from, its fate like "books" and that of adults. It has had 
its stages between the era of dull and ignorant prescribing and 
that of impotent and conceited nihilism, and of churlish pes- 
simism. But neither a deluge nor an absence of drugs make a 
physician, nor do they contribute, when alone by themselves, 
to the welfare of a single individual or of the community. 

Much has been said of the difficulty of a diagnosis in the 
diseases of infancy and childhood, and the consequent diffi- 
culty experienced in treating them. I do not believe that the 
diagnosis in the case of an adult is much easier. The latter 
will often mislead you intentionally, or because he is carried 
away by prejudices and preconceived notions; the former may 
conceal by not being able to talk, but will certainly not tell an 
untruth. Besides, the ailments of children are but rarely com- 
plicated, and a single diagnosis tells the whole story. If it be 
not made, it is perhaps best for the practitioner not to attempt 
much doctoring, and for the patient to be left alone. For, 
happily, most diseases have a tendency to get well, either com- 
pletely or partially, and many will run a more favorable course 
when not meddled with. 

This does not mean to say, however, that I discourage treat- 
ment even in such ailments as run a typical course extending 
over a number of days or weeks. On the contrary, I am op- 
posed to the practice — much too common — of those who do 
not, for instance, wish to interfere with a whooping-cough 
because it finds its natural termination after several months. 
This is true, but many of the children find their natural ter- 
mination also during these months. Every day of whooping- 
60 



GENERAL THERAPEUTICS. 61 

cough is a positive danger. A lobular pneumonia which occurs 
in the second or third month of the disease, and proves fatal or 
terminates in phthisis, would have been prevented if the origi- 
nal affection had been removed or relieved by treatment. A 
physician advising no treatment in such cases as terminate un- 
favorably in this manner, ought to be made punishable in the 
state of the future. Nor do I approve of the practice of "meet- 
ing symptoms when they turn up." My responsibility is not 
lessened by my busying myself with subcutaneous injections of 
brandy when a collapse has set in which I ought to have fore- 
seen and prevented, or with giving digitalis when on the fifth 
or sixth days of a pneumonia the pulse is flying up to 160 or 
200. Anybody can perform that sort of perfunctory expectant 
treatment extending from the first call to the writing of a death 
certificate. What I expect of a physician is to know beforehand 
whether that individual heart will carry its owner through an 
inflammatory or infectious disease without requiring stimula- 
tion or not. Many a case might be saved by a few grains of 
digitalis, or another cardiac tonic, or a few efficient doses of 
camphor or musk, if administered in time. 

Altogether, it has always appeared to me most satisfactory 
to treat children, and particularly infants. They are truthful, 
unsophisticated; they are what they appear, and they appear 
what they are. In their pathology and therapeutics there is no 
mysticism, no faith-cure, no spiritism, nor any other diabolism. 
Their diseases are seldom influenced by mental impressions and 
emotions, and for that reason "suggestion," hypnotism, or any 
other confidence game has no power over them. Their nature 
and that of their ailments are simple enough, but you must 
know how to understand them. Unfortunately, however, for 
incompetent diagnosticians, children are no mere miniature 
editions of adults, and their ills and whims and their peculiari- 
ties must be known, patiently studied, and, together with the 
ignorance and the prejudice and caprices of the parents, en- 
dured. 



62 THERAPEUTICS OF IJSTFANCY AND CHILDHOOD. 

There is one all-important principle in treating infants and 
children which cannot be repeated too often. They are very 
liable to become ansemic, to submit to general inanition, and 
suffer from failure of the heart in spite of its anatomical and 
physiological vigor. These facts render it urgent that the 
physician never lose sight of the general condition of the pa- 
tient while attending to a local disorder. 

The best treatment is preventive. Proper feeding and 
nursing of the infant prevent the numerous gastric and in- 
testinal diseases of the earliest period, which either destroy life 
at once or lay the foundation of continued ill health. For 
that reason a rather large part of my literary labors has been 
dedicated to the questions of diet and hygiene. These and 
medication belong together. That is why the first chapter 
could not help containing some remarks on medicines, and this 
one, dedicated to therapeutics, cannot abstain from referring to 
diet. Those who still object to medication on the "principle" 
of ignorance, or worse, are requested to determine the boun- 
dary-line between medicinal and hygienic agents or products. 
Attention to respiration and circulation and to the functions of 
the skin are of similar moment. Their requirements will be 
discussed in special chapters. The subjects of climate, massage, 
electricity, orthopaedics, and gymnastics will find their places' 
With the diseases of the lungs, muscles, nerves, joints, etc. 
Bathing, cold washing, exercise, sufficiently long interruptions 
of school hours to avoid exhaustion, are subjects of vital im- 
portance. The best exercise of the child is play in open air. 
Compulsory gymnastics in badly-ventilated localities cannot 
take its place successfully, and may add to exhaustion and ill 
health. It is an unfortunate fact that when the claims of 
physical development were urged upon school authorities, gym- 
nastics were added to the overcrowded curriculum as a matter 
of business necessity, or of conviction, not always willingly or 
intelligently. The summer vacations of school-children ought 
to be four weeks longer than they are. The public schools ought 



GENERAL THERAPEUTICS. 63 

to be closed about the middle of June and reopened in the be- 
ginning of October. Some years ago the Harlem Medical Asso- 
ciation and the Medical Society of the County of New York 
requested the Board of Education of the city to open the public 
schools on the third, in place of the first, Monday in September. 
The soundness of the principle was appreciated, and the neces- 
sity for such a change was acknowledged by the authorities, and 
therefore (!) the second Monday of September was selected for 
the beginning of the school season, so as to afford the children 
an extra week's boiling in the city sun and an opportunity to 
lose, as they did formerly, the benefit derived from the summer 
vacation. The sanitary reason for this loss of a beneficent op- 
portunity was said to be the virtuous anachronism of an 
eighteenth century school superintendent, who preferred the 
influence of the school-room to that of the New York streets 
for the New York boy. The good effects of the excursions of 
the St. John's Guild, and the air funds, and of the Sanitaria of 
the Guild, and the Children's Aid Society are steps in the right 
direction. 

The subject of bathing, or rather of hydr other apeutics in 
general, deserves some preliminary remarks in connection with 
a future discussion on "bathing." There is hardly a topic 
which deservedly has attracted the attention of the profession 
(and of the public) in the last decade or two, to a greater 
degree, than that of water and of its uses as a remedy. As! 
I am writing no historjr, I mention but two names which 
merit most credit in outlining both the indications and the 
methods of its uses, Winternitz, in Europe, and S. Baruch, in 
America. As its principal claim, was long considered that of 
serving as an antipyretic. The indication to reduce the tem- 
perature of the body arises when an excessive frequency of the 
pulse, degeneration of the tissues of the heart and other mus- 
cles, of the kidneys and of the brain, dryness of the mucous 
membranes, and impairment of absorption appear to result from 
it. Cerebral symptoms, such as delirium and convulsions, are 



64 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

then not uncommon at all. Particularly is that so in the onset 
of a disease, while the same temperature may be readily endured 
at a later stage. That is why the elevation of temperature 
alone, without dangers present or feared, should yield no indi- 
cation for treatment; indeed, many a child bears easily a tem- 
perature which carries danger to another; and there are high 
temperatures in some diseases, such as many forms of typhoid 
fever or of intestinal autoinf ection, which do not seem to inter- 
fere much, for a while at least, with the ease and comfort of the 
patient. Unfortunately, however, the thermometer, ranging 
103° F. or more, is too often permitted to establish indications, 
and the reduction of temperatures appears to become the only 
acknowledged duty of many practitioners. 

To reduce temperatures we have drugs and water. Of the 
former, quinine should not be relied on except in malaria, also 
in some septic fevers, when it may Fe used by itself or in com- 
binations. The coal-tar preparations, antipyrin, acetanilide 
("antifebrin"), phenacetin, etc., will all reduce temperatures, 
and have their occasional indications, but are known to depress, 
one more the other less, the action of the nervous system, and 
the functions of the heart, and even to destroy blood-corpus- 
cles. Their administration requires the utmost care, and fre- 
quently the combination with stimulants to guard against 
detrimental effects. 

Water, when properly employed, lowers the temperature, but 
has none of the depressing effects of the coal-tar antipyretics. 
On the contrary, it stimulates the nerves of the skin and by 
reflex those of the whole system, particularly of the heart; it 
increases heart and arterial pressure, thereby aids oxidation 
of tissues, and diuresis, and appears even to increase the 
amount of haemoglobin and of red cells. In this respect there 
can be no longer a difference of opinion; but in regard to the 
use of cold washing, with or without friction or effusion, of 
packing, of ice applications, of hot, warm, or cold baths, of the 
duration of an application or of a bath, and of the degree of 



GENERAL THERAPEUTICS. 65 

temperature requiring or permitting their employment in an 
individual case, no iron-clad rule will ever hold good. 

A cold bath (60° to 75° F.) is seldom, if ever, appropriate for 
a baby of less than eight months or a year, and never in con- 
genital heart-disease. It ought to be interrupted when the 
child begins to shiver, or the lips become bluish; it cannot be 
expected to have a good effect unless the feet share immediately 
in the reaction which should take place after the bath. A 
cold bath should be accompanied with friction of the surface, 
mainly of the extremities. A warm bath (85° to 98° F.) dif- 
fers so much from the temperature of a feverish child that a 
reduction will also be readily accomplished by it. Besides, the 
patient submits to it more readily. If necessary, the tempera- 
ture of the bath decreases from minute to minute, or may be 
lowered by adding cold water. Packs of cold water, iced or 
not, need not, in most cases ought not to, cover the whole body 
of the child; feet and legs should be left out. A single thick- 
ness of a common towel or napkin is wrapped around the body 
exclusive of the arms, either the chest alone, or the chest and 
abdomen, or both, and the thighs, according to the more local 
or more general effect which is to be attained; and a flannel 
sheet or blanket should cover the pack. More minute instruc- 
tion on this point will be found in Chapter III. 

Cold applications, well wrung out, and covered with flannel 
and oil silk, to small or large surfaces, and alldwed to remain 
from twenty to fifty minutes until the skin is hot, are efficient 
stimulants. Hot baths (96° to 105° F.) act as stimulants, but 
should be given sparingly, as too exciting or exhausting for 
most patients. Short hot baths, with or without mustard, and 
with or without cold applications to the head, dilate the super- 
ficial blood-vessels, and will be found useful in an occasional 
case of pneumonia, in collapse, or to favor the cutaneous erup- 
tions of scarlatina and of measles. 

Because of its grave necessity I repeat here that milk and 
drinking-water are safest when boiled. It is to be hoped that 

5 



66 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

the practiqe of sterilizing milk devised by Soxhlet, of Munich, 
and introduced in New York by Caille, and systematically em- 
ployed by Botch, of Boston, and his followers will prove suc- 
cessful. Mental and physical labor ought to be easy and 
pleasant. Factory work for children is an abomination, and not 
only a cruelty committed against the individual child, who is 
helpless, but a danger to the future of the republic, which can- 
not be expected to thrive while the physical and intellectual 
development of the future citizen is crippled by the greed of 
the manufacturer and the recklessness or the partiality of legis- 
latures. 

In the administration of medicines excitement on the part 
of the patient must be avoided; the nervous system of infants 
and children loses its equilibrium very easily. Fear, pain, 
screaming, and self-defence lead to disturbances of circulation 
and waste of strength. Preparations for local treatment or 
the administration of a drug must be made out of sight, and 
the latter ought not to have an unnecessarily offensive taste. 
Naphthalin, iodoform, betanaphthol, rhubarb, and such like 
should be shunned. The absence of proper attention to this 
requirement has been one of the principal commendations of 
"homoeopathy," whatever that may have been the last twenty- 
five years. Still, the final termination of the case and the 
welfare of the patient are the main objects in view, and the 
choice between a badly-tasting medicine and a fine-looking 
funeral ought not to be difficult. In every case the digestive 
organs must be treated with proper respect; inanition is easily 
produced, and vomiting and diarrhoea must be avoided, unless 
there be a strict and urgent indication for either an emetic or 
a purgative. The most correct indications and most appro- 
priate medicines fail when they disturb digestion; it is useless 
to lose the patient while his disease is being cured. 

The administration of a medicament is not always easily 
accomplished. Indeed, it is a difficult task sometimes, but one 
in which the tact or clumsiness of the attendants have ample 



GENERAL THERAPEUTICS. 67 

opportunities to become manifest. For "when two do the same 
thing, it is by no means the same thing." Always teach a nurse 
that a child cannot swallow as long as the spoon is between 
the teeth; that it is advisable to depress the tongue a brief mo- 
ment, and withdraw the spoon at once, and that now and then 
a momentary compression of the nose is a good adjuvant. 
That it is necessary to improve the taste as much as possible 
need not be repeated. Syrups turn sour in warm weather, glyc- 
erin and saccharin keep; the taste of quinine is corrected by 
coffee (infusion or syrup), chocolate, and "elixir simplex," a 
teaspoonful of which, when mixed each time before use, suf- 
fices to disguise one decigramme = one and a half grains of 
sulphate of quinine. Powders must be thoroughly moistened; 
unless they be so, their adherence to the fauces is apt to pro- 
duce vomiting. Capsules and wafers are out of the question, 
because of their sizes; pills, when gelatin-coated or otherwise 
pleasant and small, are taken by many. The rectum and the 
nose may be utilized for the purpose of administering medicines 
in cases of trismus, cicatricial contraction, or obstreperousness. 
Both of these accesses it may become necessary to resort to for 
weeks in succession. 

The effect of a medicine depends on its dose and the readi- 
ness with which absorption and elimination take place. Both 
are very active in infancy and childhood; but they vary. Cu- 
rare, for instance, is eliminated speedily, and must be repeated 
quite frequently; iodide of potassium soon after its adminis- 
tration, but there are traces in the urine after some days; phos- 
phate of lime appears in the urine and feces directly; chlorate 
of potassium is excreted through the kidneys within a few 
hours, silver and mercury may take a long time, in exceptional 
cases. Absorption takes place the more readily the more the 
solution in which the medicinal substance is held is diluted; 
but it depends greatly on the condition of the surface or tissue 
which is selected for the introduction of the drug. A horny 
skin absorbs but little; inunctions require a clean surface, and 



68 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

are best made where the epidermis is thin and the net of 
lymph-ducts very extensive, on the inner aspect of the forearm 
and the thigh. A congested stomach, a catarrhal or ulcerated 
rectum, are more or less indolent, and disappoint our expecta- 
tions quite frequently. That the doses must be adapted to the 
ages of the patients is self-understood; but to establish fixed 
rules is more than merely difficult. To give as many twen- 
tieths of the dose of an adult as the child has years is a fair 
average; but this rule suffers from very numerous exceptions. 
Like foods which are tolerated by the adult, but are not toler- 
ated by the young, though their amounts be diminished in pro- 
portion to their years, so there are medicines which are not 
borne by the infant. Nor are the doses the same for every 
adult. As healthy persons thrive on different quantities of 
food, so there is a variableness in the amount of medicines re- 
quired for full effect. Besides, there are idiosyncrasies which 
in some forbid the use of a medicine apparently indicated and 
borne with success by others. There are those who respond 
quickly, and sometimes too quickly, to very small doses of 
opium; others in whom a minute trifle of mercury produces 
salivation. It is this class of cases which gives rise to much 
disappointment, and requires all the tact and foresight of a 
good physician. In some the system gets used to a drug after 
a short time. Babies, after having taken opiates for some time, 
demand larger, and sometimes quite large, doses to yield a 
sufficient effect. Some drugs are required in proportionately 
large doses. Febrifuges and cardiac tonics, such as quinine, 
antipyrin, digitalis, strophanthus, sparteine, convallaria, are 
tolerated and demanded by infants and children in larger doses 
than the ages of the patients would appear to justify. Iodide 
of potassium may be given in doses of one or two drachms daily 
in meningeal affections, while in the same one of the heart 
tonics, caffeine, must be shunned because of its — under these 
circumstances — exciting and irritating effects. Mercurials af- 
fect the gums very much less in the young than in advanced 



GENEBAL THERAPEUTICS. 69 

age. Corrosive sublimate, in solutions of one to six or ten 
thousand, may be given to a baby of two years with mem- 
branous croup in doses of a fiftieth of a grain every hour or 
two hours, for five or six days in succession, with rarely as much 
as the most trifling irritation of the gums or of the stomach and 
intestines. In urgent cases of hereditary syphilis it can and 
should be administered on a similar plan for weeks, and, some- 
what modified, for many months, to be resumed afterwards. 

If it be the object of medication to accomplish an end and 
to fulfil an indication with the least expense to the organic 
economy, and within the briefest possible time, we do not 
score a success in very many instances. Indeed, not every aim 
is reached directly, and not all indications can be fulfilled 
at a moment's notice. As the object of eating and drinking 
is the reproduction and the growth of the body, as many a meal 
is required to produce a lasting and visible effect, and as every 
one of the meals is necessary for the sum total of the final 
result, so the administration of numerous small doses of medi- 
cines extending over weeks, months, and even years may be 
demanded for a certain purpose. Particularly is this so when 
chronic ailments of the blood, tissue anomalies, or of the ner- 
vous system are concerned. To affect rhachitis, phosphorus re- 
quires weeks. The faulty sanguinification of chlorosis is 
mended by iron after weeks or months. Pernicious anaemia, 
sarcomatosis, even chorea require the persistent and protracted 
use of gradually increasing doses of arsenic. Syphilis and 
chronic conditions of hyperplasia require mercury, or the 
iodides, or both, to accomplish the desired end through months 
and even years. Even the effect of digitalis, as a heart stimu- 
lant and, by its effect on the smallest blood-vessels of the heart 
muscle, a nutrient, is obtained solely through the persevering 
administration of small doses in many cases. 

The dose of a medicine depends no less on the mode and 
locality of its administration. Modern therapeutics favor as 
much as possible local medication, like modern pathology, 



70 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

which requires local diagnoses. Subcutaneous administration 
dictates smaller doses, the rectum mostly a slight increase. 
This is a subject, however, to which we shall return. The 
manner of application results also in different effects. The in- 
unction of the officinal ointment of iodide of potassium is well- 
nigh inert; its effect is almost exclusively that of massage, for 
iodine makes its appearance in the urine after days only. 
Iodide of potassium in glycerin, rubbed into the skin a number 
of times, may eliminate iodine after a day, in lanolin after a 
very few hours. 

At this place it is well to remember the great additions to 
our therapeutical possibilities, though in a few words only. Of 
serumtherapy I shall speak below; organotherapy may be 
mentioned here. It was introduced to meet the dangers of the 
absence of "internal secretion." This is a term extensively 
employed, at first in regard to the adrenals {Brit. Med Journ., 
August 10, 1895), by Schaefer and Oliver, and generally ad- 
mitted to be descriptive and telling. It is applied to some of 
the processes, partly physiological and partly chemical, of the 
formation and disintegration of matter in different parts of 
the organism. Saliva, gastric and pancreatic juice, and bile 
are external secretions, and carried off by efferent ducts. In- 
ternal secretion, however, requires no efferent ducts, indeed, no 
glandular stricture, for it occurs also in muscle and in brain 
substance. Internal secretion is carried off into the lymph 
and blood directly. Liver and pancreas appear to have both 
external and internal secretions; but thyreoid, thymus, spleen, 
and adrenals appear to have internal secretion only. Their ab- 
sence or removal or destruction by disease causes death with 
the symptoms of a chronic infection. This may result from one 
of two sources, or from both. Either those organs have the 
function of forming certain materials required in the organic 
economy, or that of destroying poisonous effete results of meta- 
morphosis. Thus the absence or destruction or extirpation of 
the thyreoid causes cachexia, that of the pancreas diabetes, that 



GENERAL THERAPEUTICS. 71 

of the adrenals Addison's disease. In regard to the thyreoid, we 
are now certain that myxcedema and some forms of cretinism 
are favorably influenced, or even cured, by the administration 
of the thyreoid gland of animals. More particulars will be 
found under the headings of myxoedema, cretinism, exoph- 
thalmic goitre, and others. 

At best, organotherapy requires patience and time. Some 
of its effects cannot be obtained except by administering the 
substitute for the absent or defective organ persistently. Myx- 
cedema and semi-cretinism are liable to relapse when medi- 
cation ceases, or is unduly interrupted. This will not be 
corrected, it is to be feared, until a normal organ is implanted 
into the suffering organism and made to perform its physio- 
logical functions. Thus far surgery has not succeeded in yield- 
ing the coveted results. 

The rectum of the infant and child has been rising in the 
estimation of the practitioner since the times of thermometry; 
for it is certainly the safest and easiest place where to take the 
temperature. For therapeutical measures it is also invaluable. 
Its importance for the purposes of alimentation has been de- 
tailed in a former chapter. (See p. 58.) 

The rectum of the young is straight, the sacrum but little 
concave, the sphincter ani feeble, and self-control gets de- 
veloped but gradually. Thus a rectal injection is easily either 
allowed to flow out or vehemently expelled. Therefore one 
which is expected to be retained must not irritate. The 
blandest and mildest is a solution of six or seven parts of chlo- 
ride of sodium in a thousand parts of water. This may be 
made to serve as a vehicle of medicine, unless incompatible 
with the latter, which it will be but rarely. An enema which 
is to be retained must be tepid and small in quantity, half an 
ounce or little more or less, and carried up well into the rectum, 
for the immediate contact with the sphincter may produce its 
expulsion. Care must be taken to exclude air from the syringe, 
which, for small quantities, must be a well-fitting piston 



72 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

syringe, of hard rubber, with a long nozzle. This must be well 
oiled, and introduced, not straight, but with a gentle turn, so 
as to avoid folds in the anal mucous membrane (in the same 
way a thermometer ought to be introduced). The nozzle must 
not be too thin, as it is liable to be caught; the smallest nozzles 
of fountain syringes are therefore in most cases improper; the 
larger size is more appropriate for any age. The injection 
must be made while the patient is lying on his side, not on his 
belly over the lap of the nurse, for in this position the space 
inside the narrow infantile pelvis is reduced to almost nothing. 

When medicines are to be injected, the rectum ought to be 
empty, as in infants it mostly is. When it is not, an evacu- 
ating injection ought to precede the medicinal one by half an 
hour. It ought to be of the mildest possible nature, for any 
irritation of the rectum, from the local effect of an enema to a 
catarrhal or dysenteric process, reduces its faculty of absorp- 
tion. The medicinal solution must not be saturated; indeed, 
very soluble medicaments only are to be selected for medicinal 
enemata. Nor must they be acid or contain anything irritating. 
Alcoholic tinctures require relatively large quantities of water; 
quinine salts must not be selected unless very soluble, such as 
the muriate, the bromide, the carbamide, or the bisulphate. 
The addition of a small amount of antipyrin renders quinine 
very soluble. No acids must be used for the purpose of keeping 
it in solution. Salicylate of sodium, also antipyrin, exhibit their 
full power through the rectum, and permit of full doses. As 
a rule, however, the rectal doses are a little larger than those 
given by the mouth. 

Larger enemata are not retained, and are therefore utilized 
for the purpose of emptying the bowels. This effect is easily 
obtained in infants and children, for their faeces are soft and 
movable, with the exception of those cases in which improper 
medicines (large and continued doses of lime and bismuth, or 
astringents), or badly selected food (casein and starch in undue 
quantities), or an excess of the normal great length of the colon 



' GENERAL THERAPEUTICS. 73 

descendens and sigmoid flexure, have given rise to large ac- 
cumulations of hardened faeces. Small quantities are seldom 
sufficient for the purpose of relieving the bowels, unless they 
act as irritants; in this manner glycerin, pure or with equal 
parts of water, may produce an evacuation readily. An evac- 
uant injection may weigh from a fluidounce to a quart in some. 
It ought to be given while the child is lying down; the liquid 
must not enter the bowels quickly or vehemently, the fountain 
syringe not hang more than ten or twelve inches above the 
anus. If that precaution be observed, occasional pain, or faint- 
ness, or vomiting can be avoided. If water, or water with two- 
thirds of one per cent, of salt, be insufficient, more salt or soap 
may be added for the purpose of enforcing the evacuation. 
Half a tablespoonful of oil of turpentine, with a pint of soap 
and water, acts often charmingly; so does the addition of a few 
drachms of tincture of assafoetida, in conditions of constipa- 
tion, flatulency, and nervous excitability, also in convulsions; 
or glycerin in obstinate constipation. 

Large injections will have other indications besides that of 
evacuation of the bowels. In many cases of intense intestinal 
catarrh large and hot (101° to 108° F.) enemata will relieve the 
irritability of the bowels and contribute to recovery. They 
should be repeated several times daily. "When such evacuations 
contain a great deal of sticky viscid mucus, the addition of one 
per cent, of carbonate of sodium will liquefy the tough secre- 
tion. When there are many stools, and these complicated with 
tenesmus, an injection, tepid or hot, must or may be made after 
every defecation, and will speedily relieve the tenesmus. In 
such cases flaxseed tea or thin mucilage may be substituted for 
water. 

When the bowels are in a state of chronic catarrh or ulcer- 
ation, the injections ought to be particularly large and contain 
astringent or alterant medicines. Though they be expelled im- 
mediately, enough of the dissolved or suspended remedy will 
remain upon the mucous membrane. Sulphate of zinc, alum, 



74 THEBAPEUTICS OF INFANCY AND CHILDHOOD. 

acetate of lead, tannic acid, nitrate of silver, salicylic acid, 
carbolic acid, and creosote have been used in such medicated 
injections. One per cent, solutions will suffice. Salicylic and 
carbolic acid may prove uncomfortable or dangerous because 
of their effect on the kidneys, and ought to be dispensed with. 
Mtrate of silver requires some precaution. From a grain to 
five grains or more in an ounce of distilled water may be safely 
injected; but this enema must be preceded by an evacuant 
consisting of water only, and followed by one containing some 
chloride of sodium for the purpose of neutralizing the nitrate 
and protecting the anus and external parts from local irrita- 
tion. It will also be found advantageous to wash the anus and 
perineum with salt water before injecting the silver solution. 
In many cases where one of the above-mentioned agents ap- 
peared to be tolerated badly, or proved inefficient, subnitrate 
(or subcarbonate) of bismuth mixed with water, or with gum- 
acacia water, in different proportions, proved very acceptable 
and healthful. 

Suppositories are useful both for evacuating and medicinal 
purposes. Soap is utilized for the former purpose by the public 
at large, and the same material differently mixed, with or with- 
out medicinal additions, such as atropia, by the irregular trade. 
Local medicinal applications to the rectum are best made by 
means of injections, but a general effect is also obtained through 
a suppository. Opiates, and narcotics generally, exhibit their 
full power when the suppository is retained. Extract of hyos- 
cyamus, from half a grain to a grain in a suppository, to be 
repeated from two to five times daily, shows its effect in re- 
lieving vesical spasm nearly as well as when taken internally. 
Quinine is gradually dissolved and absorbed. Extract of nux, 
both in ointments and in suppositories, acts well in prolapse 
of the rectum and debility of the sphincter. 

Subcutaneous injections of remedial agents ought to be made 
more frequently than appears to be customary. The extremi- 
ties, particularly their lower halves, ought to be avoided, for 



GENERAL THERAPEUTICS. 75 

their constant motion and the relative absence of fat in their 
subcutaneous tissues are liable to give rise to local irritation, 
swelling, or suppuration. The abdominal wall is preferable. 
A sharp and aseptic needle and gentle friction of the injected 
part are all that is required. The solutions used must be clear 
and without any solid ingredients. When they have been pre- 
served for some time they ought to be filtered before being 
used, particularly when fungous growths have begun to make 
their appearance in the liquid. The latter may be preserved 
best by adding a small quantity of alcohol, salicylic acid, or 
hydrocyanic acid. The doses must be small, and the medicine 
diluted more than in the case of adults. This is mainly re- 
quired where a caustic effect is to be feared. While, for in- 
stance, Lewin advised for adults a solution of four grains of 
bichloride of hydrargyrum in an ounce of water, one or one and 
a half grains give a more appropriate solution for infants. One 
or two daily doses of eight or ten drops continued for weeks 
will prove very useful in those urgent cases of hereditary 
syphilis which are characterized by pemphigus on the soles of 
the feet and the palms of the hands in the first days after birth. 
Brandy and ether may be used undiluted as in adults, but the 
greatest care must be taken as to the locality injected. The 
subcutaneous tissue must be reached and the cutis penetrated. 
Chloral hydrate dissolves readily in two parts of water, but a 
solution of one in four or six is better tolerated. For the ready 
symptomatic treatment of convulsions it renders good service. 
Antipyrin is well borne in solutions of one in six or eight parts 
of water, camphor in from four to six parts of sweet almond 
oil. Digitalin, in solution, and the fluid extracts of digitalis 
and ergot, are very apt to give rise to indurations and, per- 
haps, abscesses. As a rule, the most convenient medicaments 
for hypodermic administration are the very soluble alkaloids. 
One or three drops of Magendie's solution of morphine or the 
corresponding solution of muriate of morphine are vastly pref- 
erable to the internal use of narcotics for bad pain in pleuritis 



76 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

or pleuropneumonia, or in peritonitis of advanced childhood. 
It may be mixed with atropise sulphas for the reasons regu- 
lating its use in the adult. The latter by itself has been found 
quite effective in the case of an epileptic boy, who had taken 
the same drug internally without any success. If possible, it 
ought to be injected during the aura; if not, twice a day. Apo- 
morphise murias is a ready emetic in doses of a thirtieth or a 
fifteenth of a grain. Pilocarpise murias can be injected in 
doses of one-twentieth to one-eighth of a grain. Its reckless 
use, both hypodermically and internally, has led to occasional 
mishaps, but the drug is a powerful agent for good when care- 
fully applied, and has saved for me several cases of meningeal 
hyperemia and cerebral oedema, mostly of nephritic origin. 
Sulphate of strychnine, while in the same affections it has 
mostly proved inefficient when taken internally, has rendered 
efficient services in enuresis depending on paralysis or weak- 
ness of the sphincter of the bladder, and in prolapse of the 
rectum, and fascal incontinence resulting from paralysis of the 
anus, which depended either on disease or congenital incompe- 
tency. In these cases a daily dose of a fortieth or a twenty- 
fifth of a grain — according to the age of the patient or the 
severity of the case — is sufficient. More frequent doses, how- 
ever, are required in the diphtheritic paralysis of the respira- 
tory muscles, which is dangerous and apt to become fatal unless 
speedily relieved. A daily dose will also yield fair results, when 
long continued, in the later stages of spinal or cerebral paral- 
ysis, where its internal administration is entirely, or wellnigh, 
useless. Quinia salts must be neutral when injected; I prefer 
the bromide, the muriate, or the carbamide. They, particularly 
the last, are among the most soluble. The carbamide dissolves 
readily in from four to six parts of warm water; the latter tem- 
perature ought to be preferred in every case of subcutaneous 
injections. Quite saturated solutions ought to be avoided, 
because it has happened to me that the water of the solution 
was speedily absorbed, and the quinia remained as a foreign 



GENERAL THERAPEUTICS. 77 

body in the subcutaneous tissue. Caffeine, in its combination 
with sodium and salicylic or benzoic acid, is an excellent heart 
stimulant, and has rendered splendid service in urgent cases 
of heart-failure or pulmonary oedema depending on cardiac 
disease. Both the salicylate and the benzoate of sodium and 
caffeine are soluble in two parts of water, and are readily ab- 
sorbed. Both must be avoided in those cases which are com- 
plicated with cerebral irritation or sleeplessness. Fowler's 
solution, carefully filtered and diluted with at least twice its 
quantity of distilled water, may be injected into healthy or mor- 
bid tissues without often risking irritation and abscess. Still, 
I have seen a splenic abscess after such an injection in a case 
of sarcoma of the spleen. Undoubtedly, the continued use of 
arsenic renders very efficient services in sarcoma; but as it has 
to be used a very long time, it is almost impossible, except in 
hospital practice, to resort to hypodermic medication. There is 
no harm in this, however; for a very gradual increase of the 
drug is tolerated by the stomach to such an extent that, after 
awhile, very large doses (amounting to half a drachm = two 
cubic centimetres) of Fowler's solution daily, well diluted, may 
finally be administered after meals. 

Subcutaneous injections have reached an extensive field of 
usefulness in serumtherapy. After it was proved that animals 
could be immunized against certain virulent bacteria, it was 
found that the blood-serums of previously immunized animals* 
could be utilized as powerful remedies in infectious diseases of 
man. In the chapter on diphtheria more will be said of the 
effect of its antitoxin, the preparation and knowledge of which 
is due to Aronsoii, Eoux, and Behring. Tetanus and diph- 
theria are certainly influenced by their proper antitoxins to 
a remarkable degree. Asiatic cholera is likely to be the next 
great scourge of mankind to be stripped by its antitoxin (Haff- 

*Not to be mistaken for the congenital protection afforded by the 
presence in the blood-serum of the newly-born of "alexins." 



78 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

kin) of part of its fury. Neither Marmoreck nor others, how- 
ever, have thus far succeeded in producing an antitoxin which 
is as effective as those of tetanus and of diphtheria in such 
infectious diseases as appear to be connected with, or depend- 
ent on, streptococci (puerperal diseases, erysipelas, scarlatina, 
and some forms of abscesses, of angina, and of diphtheria). 
Nor are the claims of Coley, who, with antitoxin procured 
from the coccus of erysipelas and from bacillus prodigiosus, 
■exhibits interesting results in sarcomatosis (not in carcinosis), 
generally accepted by all. In many more diseases antitoxins 
have been recommended; prematurely it appears, for neither 
croupous pneumonia, nor typhoid fever, nor syphilis has been 
benefited thus far. Nor have the attempts at obtaining an 
antitoxin to take the place of calf vaccinia in the immuni- 
zation against variola been successful. Not infrequently the 
lymph usually employed is mixed with bacteria and other im- 
purities. Thus far, however, a sterile blood-serum of the vac- 
cinated calf could not be obtained in sufficient condensation 
and efficacy. 

In organotherapeutics the hypodermic method is no longer 
employed extensively, since the internal administration of the 
different tissues, or its extracts, or other modes of preparations, 
are both efficient and (mostly) palatable. 

The subcutaneous injections of cocaine, according to 
Schleich's method of "anaesthesia by infiltration," will prove a 
great gain to the practitioner, inasmuch as, with or without the 
previous use of ethyl-chloride, it will facilitate many opera- 
tions. Maybe its principal advantage will lie in this, that many 
abscesses and furuncles will be dealt with before they are per- 
mitted to get larger. Their antineuralgic action will not be re- 
quired frequently, because of the relative scarcity of neuralgias 
in childhood. In almost every case the solution is to consist of 
cocaine muriate 0.1, morphia sulphate 0.02, chloride of sodium 
0.2, distilled water 100.0 (5 : 1 : 10 : 5000). 

Inhalation is resorted to in two different ways. Either the 



GENERAL THERAPEUTICS. 79 

air of the room or a tent is impregnated with the substances 
to be introduced into the air-passages, or these substances are 
introduced through sprays or atomizers of different shapes and 
patterns. Some of the latter have always appeared to me very 
faulty, and not to the purpose at all. Tubes introduced into 
the mouth, through which substances are to be carried down, 
will land them in the mouth; it takes all the self-control and 
intelligence of an adult patient to allow the object in view to 
be accomplished. The oral cavity of the infant or child is small, 
the tongue gets coiled up, and the faucial muscles will not relax. 
Nose and mouth must co-operate to allow inhalations to enter 
the larynx, or the former alone must be relied on. A spray cal- 
culated to reach the larynx of infants or children is always best 
introduced into and through the nose. In this way, at all 
events, the posterior part of the pharynx and the respiratory 
tract are reached to best advantage. The manner in which the 
spray is employed in diseases of the nose and pharynx is quite 
often too perfunctory, with no other result but to make the 
patients wakeful and restive. 

Eeal inhalation, however, means filling the lungs with a gas 
or vapor. Warm steam will do good service in bronchitis and 
pneumonia, when the bronchial secretion is viscid and expec- 
toration difficult, and in diphtheria, for the purpose of soften- 
ing membranes and increasing the secretion of a thin and 
normal mucus. Cases of fibrinous bronchitis I have seen get- 
ting well in bath-rooms, the hot water being turned on for 
days in succession and the air thick with steam. An excel- 
lent inhalation in the inflammatory conditions of the respira- 
tory organs is that of muriate of ammonium. Every hour, 
or in longer intervals, a scruple or more of the salt — the quan- 
tity depending in part on the size of the room — is burned on 
the stove, or over a live coal or an alcohol-lamp. The heavy 
white cloud fills the room, is easily borne by both sick and 
well, and improves expectoration. Oil of turpentine can be 
utilized in a similar way. Its action is both expectorant and 



80 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

disinfectant. In the latter stages of pneumonia, when the 
bronchial secretion is thick, viscid, or deficient, and expectora- 
tion and cough are wanting, the room may be filled with tur- 
pentine vapor. This can be accomplished in different ways. 
A large soft sponge may be soaked with turpentine, with or 
without the addition of some oil of sassafras, and suspended 
at the bedside. Or a kettle may be kept boiling day and night 
with water, on the fireplace or over an alcohol-lamp (this is 
preferable to a gas-stove, which consumes too much oxygen), 
and a tablespoonful of turpentine, more or less, poured on the 
boiling water every hour or two hours. The same may be done 
to advantage in diphtheria, with or without a teaspoonful of 
carbolic acid in addition to the turpentine, and in gangrene 
of the lungs. The inhalation of benzine, cresolin, and similar 
substances, and of the coal-gas of the gas-factories, has been 
amply recommended in whooping-cough. In its worst forms, 
particularly when it is complicated with convulsions, the fre- 
quent inhalation of chloroform is sometimes life-saving. A 
baby of six months, with hourly attacks of convulsions, I kept 
alive by putting him under the influence of chloroform at the 
beginning of every attack, and continuing that treatment for 
fully four days. Asthmatic attacks will do well sometimes 
with inhalations of chloroform, ether, and spirits of turpen- 
tine in different proportions, mostly 1:2:4. Mtrite of amyl 
also will influence them favorably; as a preventive of epileptic 
attacks I have experienced but little success with its admin- 
istration. But in collapse, with paralysis of peripherous blood- 
vessels, it certainly renders good service. With the inhalation 
of oxygen for the purpose of bridging over the most dangerous 
period of a suffocating pneumonia, and of improving tissue- 
change in general ansemia and ill-nutrition, the profession is 
well acquainted. With the inhalation of ether as an antidote 
to poisoning with santonine I have no personal experience. 
Ozone inhalations have been highly recommended in ansemia, 
whooping-cough, and septic fevers. We shall have to learn 



GENERAL THERAPEUTICS. 81 

more of its effects, and particularly in regard to a ready and 
reliable method of its preparation.* 

In pulmonary tuberculosis the inhalation of disinfectant 
vapors is employed less than the necessity of the cases appears 
to indicate. Carbolic acid, turpentine, eucalyptol have been 
utilized for that purpose. The object is to supply the lungs 
with those substances in thin dilutions, but constantly. Prud- 
den has proved that carbolic acid in twelve hundred parts of" 
water stops the emigration of leucocytes in inflammatory dis- 
orders. Thus high dilutions, though they be hardly percep- 
tible to the senses, and certainly not to a disagreeable extent, 
may be amply sufficient. It is for this reason that Feldbausch 
invented small apparatuses filled with a disinfectant substance 
to be worn in a nostril, constantly. 

The inhalation of chloroform, which is preferable to ether 
for the purpose of producing anaesthesia in the cases of infants 
and children, is rather unsatisfactory at the earliest age be- 
cause of the superficial character of respiration. So is that 
of ether, which, moreover, may become contraindicated in every 
period of life because of its detrimental effect on kidneys and 



* After the above was written a letter was received from Dr. A. 
Cattle, dated August 9, 1897, in which he says: "That the oxyheemo- 
globin will increase markedly and rapidly under the use of ozone in- 
halations is a fact which can be demonstrated in any case of chlorosis 
or secondary anaemia. I can also show you a middle-aged woman 
who four years ago had a bad pulmonary tuberculosis, and is absolutely 
cured after three years of ozone inhalations. No trace of the former 
extensive lung infiltration can be detected. As regards pertussis, the 
duration and severity of the attacks are unquestionably shortened. 
What is wanted is a cheap home machine made up of dry cells or spark 
coil and ozone tubes. The apparatus in the market costs seventy-five 
dollars. A large apparatus to use with the street current I can show 
you in the Babies' Wards of the Post-Graduate School and Hospital. If 
a glass tube with rubber tube attached is placed between the poles of a 
static machine, therapeutic quantities of ozone can be conveyed to the 
patient." 

6 



82 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

on the respiratory organs. It frequently begets nephritis, bron- 
chitis, and pneumonia. The effect of the anesthetic is very 
temporary, and the administration must be repeated and closely 
watched during a convulsion or an operation. The difficulty 
in obtaining a complete narcosis is particularly great in the 
newly-born. The stage of excitement is but brief, the pulse 
becomes frequent, and the pupils contract. After a short time 
the pulse, however, becomes slow, and the pupils dilate. The 
after-effects are not so inconvenient as they often prove in the 
adult; children vomit less frequently and less profusely, and 
certainly with greater facility and ease than adults. They are 
liable to remain under the influence of the anaesthetic a long 
time after an operation has been completed. After trache- 
otomies, which I never performed without chloroform unless 
the children were asphyxiated by carbonic acid poisoning, the 
patients are apt to sleep long and undisturbed. Thus they 
require a ceaseless watching until the effect has surely passed 
away. Through the opened trachea the children will get 
under the influence of chloroform very easily. Five or six 
drops on a sponge or on some absorbent cotton, held in the 
mouth of the tube by means of a pair of pincers, have an almost 
instantaneous effect, and came near destroying, when I under- 
took to change the tracheal tube on the third day, a successful 
case of mine nearly thirty years ago, before I had the experience 
detailed in the previous remark. Further care is also required 
in regard to patients in ill health. Chronic pulmonary and 
heart-diseases do not tolerate chloroform very well, but the 
diagnosis of these conditions is more readily and quickly made 
in children than in the adult. Adipose children are liable to 
faint. The usual operations in the mouth, such as resection 
of tonsils, incision of abscesses, it is best to perform without 
an anaesthetic, for the amount required to overcome the re- 
sistance of the masseter and buccinator is so large, generally, 
as to possibly endanger the life of the patients, besides the im- 
possibility of obviating successfully the entrance of blood into 



GENERAL THERAPEUTICS. 83 

the digestive organs, where it is inconvenient, or into the res- 
piratory organs, where it is a positive danger. 

Gargles of any description require a certain degree of train- 
ing and self-control, and are therefore rarely available for chil- 
dren of less than seven or eight years. The liquids thus em- 
ployed do not reach any farther than to the uvula, the pillars 
of the soft palate, and the anterior part of the tonsils. What- 
ever succeeds in passing them is swallowed. Thus the alleged 
efficacy of gargles is greatly over-estimated. Astringents only 
have a certain influence reaching beyond the area of contact, 
but through their secondary effect on contiguous tissue only. 
When a thorough effect is aimed at, it is better to rely on sprays, 
which may affect the whole pharyngeal cavity, or on insuffla- 
tions of powders. As, however, in most cases where a local 
effect on the pharynx is desirable, the local affection spreads 
over the posterior nares as well, spraying, or injecting, or irri- 
gating the nose is preferable. The liquids thus employed 
reach the pharynx, and are either swallowed — which is often 
an indifferent matter — or expelled through the mouth. When 
these methods are undesirable, for instance, when the liquids 
injected enter the Eustachian tube, they may be poured into 
the nasal cavities from a teaspoon or a pipette. A common 
medicine-dropper will often suffice. There is many a case of 
diphtheria in which the very gentlest method of cleansing and 
disinfecting the surface of the naso-pharyngeal cavity ought 
to be selected. More on this subject will be said in another 
part of this book. 

When no liquids are tolerated, fluid ointments may be in- 
troduced into the nostrils by means of a eamePs-hair brush, 
or poured in. Ointments prepared with vaseline, glycerin, or 
cold cream are good vehicles for that purpose. Sponges and 
brushes ought to be avoided whenever the young patient ob- 
jects to these strenuously. No violence must be used, for 
several reasons. The child's strength must not be exhausted 
by his attempts at self-defence, and most local affections of the 



84 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

throat get worse by any injury done to the epithelia. Even 
galvano-cauterization can and must be applied without much 
violence. Persuasion, patience, and cocaine will render its 
employment possible in many instances. 

The skin in infancy and childhood participates in the ana- 
tomical structure of all the tissues at that early period, inas- 
much as it contains more water than in advanced age. Be- 
sides, it is thinner, and its lymphatics are more numerous, 
larger, and more superficial. This explains some peculiarities 
in regard to the effects of many medicaments. Electricity in 
all its forms is more efficient, and a relatively mild current 
suffices. This fact is of particular importance, as, moreover, 
the bones also are thinner and more succulent. To act upon 
the brain, very mild currents only must be used. The spinal 
cord is less accessible, and appears to require rather large doses. 
The galvano-caustic effect resembles very much that obtained 
in the adult. In most cases it should be closely watched while 
being employed; thus, for instance, in the operation on angi- 
omata, or diseases of the tonsils or nose, it readily destroys 
more than was intended. 

Sinapisms, when not mixed with flour, must not be per- 
mitted to remain more than a few minutes. As soon as the 
skin begins to be discolored they should be removed. When 
that is done, they may be repeated every few hours, and they 
are active derivants in many cases of deep-seated congestive 
processes. The same remark is due in reference to the use 
of mustard-baths. A hot mustard-bath renders good services 
in suppressed or insufficient cutaneous eruptions of an acute 
character, internal hemorrhages, meningitis, and pneumonia. 
But it must not be continued beyond reddening the skin. 

Vesicatories have lost much of the esteem in which they were 
held in former times. I remember the time when many a 
case of pleurisy, articular inflammation, herpes zoster, was not 
permitted to get well without a Spanish-fly blister. Nor am 
I of the opinion to-day that it will do no good in some such 



GENERA T. THERAPEUTICS. 85 

cases, provided it be not used during the feverish stages. But 
their drawbacks are many. A plaster will not stick to an 
emaciated and uneven surface, and is even apt to give rise to 
gangrene when the surface circulation is very defective. In 
these cases the wound will heal badly. The skin of the infant 
being very vulnerable, eczema and impetigo will easily arise on 
ever so slight a provocation. The local pain of the application 
produces irritation*, nervousness, and sleeplessness. This is 
particularly so if the application be made on the extremities 
or on the posterior surface of the body. The kidneys are fre- 
quently affected by cantharides, dysuria being the result in 
many cases, which then require energetic camphor treatment 
for the relief of the torturing symptoms. 

There are some absolute contraindications to the external 
use of cantharides: the presence of diphtheria in any shape or 
manner, and such diseases as are liable, during the prevalence 
of an epidemic, to become complicated with diphtheria. 
Therefore no vesicatory must be used during nasal, pharyn- 
geal, or laryngeal diphtheria (croup), or in the different forms 
of pharyngitis, or in laryngeal catarrh, or in erysipelas. 

"When a plaster cannot be expected to remain on the surface 
and to have its full effect, cantharidal collodion may take its 
place. The application will prove more effective when the 
surface is first washed with vinegar, or irritated by a sinapism, 
which, however, is allowed to remain a few minutes only. 
Then a flaxseed-poultice or warm-water applications may be 
applied over the vesicatory to diminish the pain and accelerate 
the effect. Very young infants ought not to carry a vesica- 
tory more than an hour, at least not on the same spot. That 
is why to them the cantharidal collodion is less adapted. The 
plaster may be shifted from place to place. 

After the epidermis has been raised, the serum must be al- 
lowed to escape through small punctures, but not so as to 
moisten the adjoining parts, for the cantharidin contained in 
the serum may exert a disagreeable local effect. The epider- 



86 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

mis ought not to be removed, and no irritating ointment used 
to keep up a secretion. To cover the sore surface, vaseline or 
cold cream are preferable to common fats, which may be, or be- 
come, rancid. The best final dressing is borated cotton and a 
bandage. Vaseline ointments with opium, lead, or zinc, and 
powders of zinc, subnitrate of bismuth, iodoform and amylum, 
in equal parts, or salicylic acid one part, with twenty-five of 
starch, will find their occasional indications. 

In many affections of the skin powders, solutions, liniments, 
ointments, and baths are employed. The skin is thin and 
irritable. Erythema will follow the contact with water quite 
often; thus many forms of dermatitis contraindicate its fre- 
quent use. Acute and chronic eczema get on better without 
than with it. Therefore astringent solutions are less advisable 
than astringent ointments. For superficial effect these must 
be prepared with vaseline or cold cream, either of which may 
be readily combined with lead, tannin, zinc, bismuth, salicylic 
acid, or iodoform. In not a few cases, on a very sore sur- 
face, denuded of its epithelium and oozing, the powders alone, 
or combined with starch in different proportions, will prove 
very effective. Oleates ought to be avoided, — they irritate the 
skin and produce eruptions. 

As the skin is thin and succulent, and the lymph-ducts of 
the young quite superficial, large, and numerous, substances 
will penetrate the skin quite readily. Ointments with that ob- 
ject in view must be prepared with animal fats, particularly 
with adeps lanae hydrosus of the TJ. S. Pharmacopoeia (lanolin), 
to the latter of which, when rather dry, ten per cent, of water 
may be added. Still, much friction may by itself irritate the 
surface and give rise to suffering. 

In the very young, ice and ice-water applications are not 
tolerated a long time. Ice to the cranium, the bones of which 
are but thin, is liable to produce collapse; about the neck and 
occiput it is better borne and often beneficial. Warm fomen- 
tations and hot poultices are very beneficial in many morbid 
conditions of the trunk and extremities, but dangerous when 



GENERAL THERAPEUTICS. 87 

applied to the head and not carefully watched. General baths 
are frequently required, local baths but seldom; foot-baths may 
be given while the patient is lying down, but hot fomentations 
are more readily made, and do not require the same amount 
of watching, nor are they equally objectionable to the young 
patient. 

Depletions were frequently resorted to scores of years ago. 
Modern practice has learned how to do without them, though 
we may be willing to assume that they were more frequently 
indicated than many of us believe at present. At all events, 
it ought to be taken into consideration that there is but a single 
pound of blood in a baby of twenty pounds, and that a patient 
rapidly reduced by sickness is least able to stand a loss of blood 
ever so small. Thus a venesection will hardly ever be thought 
of; at all events, I hope never to repeat the opening of a ju- 
gular vein, practised by me in a case of convulsion depending 
on, and increasing, cerebral congestion, a third of a century 
ago. Local depletions were once more frequent, though the 
liability of the skin to inflammation and furuncle was well 
understood, and the excitement of the little patient was such, 
now and then, as to lead to an increase of the symptoms, and 
even to convulsions. Among the occasional drawbacks was 
also the possible loss of blood after the leeches had fallen off. 
In such a case the local use of tannic acid, alum, perchloride 
or subsulphate of iron, digital pressure, or in bad cases the 
ligature underneath a harelip needle, which was inserted 
through the wound, were resorted to. A solution of from 
twenty to fifty per cent, of antipyrin in water, to which tannic 
acid may be added or not, is a powerful styptic. The indica- 
tions of depletion were bad and painful cases of pleurisy and 
peritonitis, and cerebral inflammatory diseases. In the latter, 
the mastoid process and the septum narium are the points on 
which the leech or leeches ought to be applied. It is the latter 
spot which I prefer, when I have the choice, in those rare cases 
of brain-diseases of infants and children in which I still feel 
justified to recommend a depletion. 



III. 

TREATMENT OF THE NEWLY-BORN. 

1. Asphyxia. 

The prognosis of asphyxia and of its treatment is a very 
doubtful one in many cases. It depends not only on the 
knowledge and skill of the physician, but on the causes of the 
abnormal condition. A moderate or serious compression 
of the head, compression or prolapse of the cord, intrauterine 
respiration and aspiration of foreign bodies (amniotic liquor, 
meconium), apoplexy, anaemia of the foetus, accumulation of 
carbonic acid in the blood, poisoning by morphia, or chloral, 
taken by the mother, or by her excessive temperature, con- 
genital diseases, and malformations, each of them, or several 
combined, influence both the prognosis of the individual case 
and the result of therapeutic procedures. 

When the long duration of labor, the prolapse of the cord, 
the protracted compression of the head, the early loss of amni- 
otic liquor, or a high temperature of the mother endangers the 
life of the foetus, the best preventive of asphyxia is the artificial 
termination of parturition. The respiratory organs of the 
foetus passing out of the vagina should be protected from con- 
tact with copious discharges of liquor amnii and other foreign 
material accumulated in the bed, and the face be raised so that 
aspiration, mostly through the nose, cannot take place. The 
mouth of the newly-born, unless it cries lustily, must be 
cleansed immediately, but very gently, by a moistened piece 
of cloth wrapped round the finger, the tongue drawn forward, 
and the baby placed on its side before attention is paid to any- 
thing else. Beating the nates, tickling of the fauces by means 
of the feather of a hen or a goose, and the momentary inhala- 



TREATMENT OF THE NEWLY-BOEN. 89 

tion of ammonia can be resorted to before the baby is separated 
from the placenta. Most practitioners, indeed, will prefer to 
prolong the connection with the maternal organ until the pul- 
sation of the cord begins to flag, under the usual circumstances. 
The separation of the baby must take place immediately when 
there is no pulsation in the cord, or when asphyxia is well pro- 
nounced. When the baby is strong and cyanosis marked, 
Grenser recommended to allow the cord to bleed before the 
application of the ligature. When bleeding was but scanty, 
he increased it by placing the baby in a warm bath. This pro- 
cedure I have imitated several times with advantage. 

When the ligature has been applied and the baby removed, 
the mouth of the asphyctic infant ought to be cleansed again 
as above, quickly but gently. For amniotic liquor, meconium, 
and vaginal secretion, when aspirated, will, though the as- 
phyctic condition may be relieved, give rise to bronchitis and 
pneumonia after two or four days. Many babies die in this 
way. 

Insufflation into the lungs for the purpose of establishing 
respiration has been practised by Smellie as early as 1762. It 
is done from mouth to mouth, from mouth to nose, or by 
the catheterization of the larynx. The first method is not 
reliable, for the tongue is liable to close both pharynx and 
larynx; the second is often successful, but may inflate the 
stomach as well as the lungs. By inflating the former the 
chances for a normal action of the lungs become less. After 
every insufflation which fills the lungs, the chest ought to be 
compressed by two hands over the lower latero-anterior region 
of the chest-walls. 

The direct insufflation of the lungs may become detrimental 
for several reasons. H. Reich relates the case of a consump- 
tive midwife who was reported to have infected twelve infants 
with acute tuberculosis in thirteen months. In the practice 
of another midwife, who was healthy, in the same town, no 
such case occurred. During nine previous years there were 



90 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

but two cases of tubercular meningitis, and but one in the year 
following the death of the consumptive woman. Moreover, 
the act of insufflation may prove dangerous by the impossibility 
of limiting the force of the entering volume of gas. Eupture 
of pulmonary tissue and emphysema and pneumothorax have 
been observed. The same accident may occur when a catheter 
is used for the same purpose. It has, however, the advantage 
of permitting the sucking out of the aspirated material before 
air is blown into the lungs. Ribemont's and others' metal 
catheters cannot be carried much below the vocal cords. An 
elastic catheter, guided by a wire which allows any degree of 
bending and may be withdrawn when the vocal cords have been 
passed, is better adapted both for aspiration and inflation. 

The asphyctic baby ought to be plunged into a warm bath 
(100° F.) immediately, and gently rubbed. The other methods 
may be continued during that time, — beating, tickling, elec- 
tricity. When it is thin, pale, and collapsed, a hot injection 
into the bowels (104°-108°) will render good service. The 
quick and repeated alternation between the warm bath of a 
minute and a cold one of one or two seconds, or the pouring 
of cold water on chest, or neck, while the body is in the warm 
bath, restores many. But great care must be taken lest the 
latter be too hot. It may produce convulsions, and has been 
known to give rise to tetanus. Before, and after the bath, in- 
deed at any time, the vigorous swinging of the baby on the 
arms of the medical man is a good adjuvant. 

Among all the mechanical methods of artificial respiration 
(Marshall Hall, Silvester, Howard, B. Sehultze, Pacini, Woih- 
ler, Bani, S chillier, Dew, and others) those of Silvester and 
Sehultze render the best services in the asphyxia of the newly- 
born. Both are very simple, and either of them is effective. 
A. Brothers prefers the former ("Infantile Mortality during 
Childbirth and its Prevention," Philadelphia, 1896). 

Silvester places the patient on his back, a small pillow (piece 
of clothing, towel, sheet) between the shoulders, the tongue 



TREATMENT OF THE NEWLY-BOBN. 91 

drawn forward. The two arms are caught above the elbow 
and while being everted are slowly carried upward. Thus the 
chest is expanded. Then they are carried downward and 
pressed against the sides of the chest, a little anteriorly to the 
axillary line. Thus the lungs are compressed. This com- 
bined action may be repeated fifteen or twenty times in a 
minute, and a hot bath given afterwards. Then the pro- 
cedure is renewed. 

B. Schultze places his index-fingers into the axillas, the three 
other fingers gently against the sides of the chest, the thumbs 
covering the shoulder from behind. The infant is then swung 
forward. The lower extremities bend on the abdomen, the 
abdomen presses against the diaphragm, and the lungs are 
compressed, — expiration. The parts then return slowly down- 
ward and swing back, thus expanding the chest, — inspiration. 
This action may also be repeated fifteen or twenty times in a 
minute. After each minute's swinging the baby is placed in 
a warm bath. There, is but one (occasional) contraindication 
to the employment of this method, — viz., the insufficient de- 
velopment of the foetal bones. When the newly-born is too 
premature, and the ribs too soft and flexible, it is useless. It 
is also contraindicated in the plethoric, congestive variety of 
asphyxia. That proper caution should be exercised is self- 
understood. In a case published in the London Lancet of May 
8, 1897, the infraspinatus and teres minor muscles were injured 
so as to cause rotation and adduction of one arm. 

During all this time, whenever feasible, the surface of the 
infant must be kept warm artificially by hot blankets, stones, 
bottles, and a few drops of brandy, whiskey, camphor-water, 
or tincture of musk, or a drop of tincture of belladonna, may 
be given in some hot water if deglutition is possible, or a larger 
quantity (some ounces) of hot water (104 o -110° F.) injected 
into the rectum. When the main difficulty appears to be, after 
a while, in the excessive debility of the heart, it is possible that 
a five-hundredth part of a grain of nitroglycerin, repeated 



92 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

after fifteen and thirty minutes, will render good and speedy 
service through its ready absorbability on every mucous mem- 
brane. I have no experience with it in the asphyxia of the 
newly-born, but its rapid action in failing heart and collapse 
and shock from other causes encourages me to recommend it 
for a fair trial of its powers. 

Laborde was very successful by drawing the tongue of the 
asphyctic baby forward in rhythmical alternations. That pro- 
cedure is to be repeated ten or fifteen times a minute. It does 
not seem to be promising unless the reflex irritability of the 
medulla oblongata is rather intact. 

Electricity was recommended in cases of asphyxia as early 
as 1793 by Huf eland. But the first case, in which the rhyth- 
mical faradization of the phrenic nerve and its associates was 
resorted to (Ziemssen) for the purpose of producing artificial 
respiration, was that of an asphyctic girl poisoned by carbon 
oxydul. The phrenic nerve acts on the diaphragm. Its aids 
are the cervical plexus, which controls the trapezius, levator 
scapulae, and middle scalenus muscles, and the brachial plexus. 
The ramifications of the latter are the anterior thoracic nerve 
for the pectoralis major and minor; the posterior thoracic for 
the middle scalenus, posterior superior serratus, and the rhom- 
boid muscles; and the lateral thoracic for the serratus anticus 
major. 

In many cases since, such as poisoning by chloroform, coal- 
gas, opium, diphtheria, sulphide of hydrogen, and pernicious 
intermittent fever, also in those of apoplexy, drowning, and 
hanging, electricity has been employed to advantage. Its effect 
is often rapid and powerful. 

In asphyxia of the newly-born, the systematic faradization 
of the phrenic nerve has been first employed by Lauth and 
Pernice. 

The point of application selected by most authors is near the 
sterno-cleido-mastoid muscle, over the phrenic nerve. The 
other pole is applied either to the neck or to the diaphrag- 



TREATMENT OF THE NEWLY-BOKN. 93 

matic region or any other part of the surface. The localiza- 
tion of the effect to the phrenic nerve alone, which was insisted 
upon by many, is certainly an illusion. The current will surely 
strike the pneumogastric, phrenic, sympathetic, and many sen- 
sitive and motory nerves at the same time. As this cannot be 
avoided, as indeed it is better that it should be exactly so, it is 
best to use large sponge electrodes and moisten them thor- 
oughly with salt water. The head, arms, and shoulders should 
be slightly raised, and a small pillow placed between the, shoul- 
ders for the asphyctic baby to rest on. One of the electrodes 
must be kept stationary; the other brought into contact with 
the surface but a single moment. A deep inspiration will then 
take place, the lungs will expand, and lateral pressure on the 
lower part of the chest should be resorted to for the purpose of 
emptying the lungs afterwards. Another application is then 
made with the same result, and must be followed with the same 
manipulation. This has to be continued for some time until 
the baby cries, and it appears safe to discontinue the applica- 
tion. Whenever a cough or a coughing movement is noticed, 
it should be omitted temporarily. The favorable result, how- 
ever, is not always permanent. The causes of the asphyctic 
conditions are still active, and the infant will require resuscita- 
tion again, and perhaps many times. Thus close attention 
must be paid, sometimes for hours. 

Great care should be taken in regard to the duration of the 
application. Continued or too frequent irritation by the cur- 
rent causes over-irritation and paralysis. ISTot infrequently is 
the immediate effect a favorable one, inspiration becoming 
deep and the heart active, but after a short time the former 
grows more superficial, the pulse feeble, and the C3^anotic hue 
returns to the lips and finger-nails. Then it is time to stop 
for a while, and resort temporarily to other means of resuscita- 
tion. Thus the practice of Lauth's, who applied the current 
persistently for two or three minutes, is decidedly improper 
and dangerous. 



94 THERAPEUTICS OE INFANCY AND CHILDHOOD. 

In some cases, where the interrupted current is inefficient, 
the galvanic (continuous) current, with occasional reversions, 
has been known to yield better results. In my own cases I 
have never had an opportunity or been under the necessity of 
employing it. 

The application of large sponge electrodes may not always 
be convenient. In those cases no harm is done by using the 
metal poles instead. Though the irritability of the brain (and 
nerves) is but low in the newly-born, the pain produced by the 
interrupted current thus applied is very intense, and the effect 
on the contraction of the diaphragm quite marked. Thus it 
is not necessary to lose time for preparing, if it be not on hand, 
the more complicated apparatus. Still, exhaustion is more 
readily obtained through resuscitating by pain and muscular 
action combined than by muscular contraction alone. In most 
cases, however, I was satisfied with not losing even a fraction 
of a minute, particularly in those early times, where the most 
convenient apparatus was the old-fashioned rotating machine. 

How long is the asphyctic baby to be watched and the at- 
tempts at resuscitation to be renewed? At all events they 
must not be given up as long as the heart-beats are audible, 
though ever so feebly. Nor is a single scream sufficient to per- 
mit watchfulness to be relaxed. The deep recession, during in- 
spiration, of the diaphragmatic region (the "peripulmonary 
groove" of Trousseau) should have ceased, the cry be vigorous, 
the eyes wide awake, and the extremities in lively motion. Be- 
fore this is accomplished there is danger of a relapse, partly 
from impaired innervation and the continuation of some of 
the causes of asphyxia, and partly from obstruction through 
mucus, which may be coming up constantly and gather in the 
pharynx and posterior nares. 

2. Postnatal Asphyxia and Atelectasis. 
Atelectasis may be congenital or acquired. The lungs may 
never have expanded to their normal degree, or after expan- 



TREATMENT OF THE NEWLY-BORN. 95 

sion had taken place, they may have collapsed, or contracted 
again. The causes of this condition may also be either con- 
genital or acquired. There may be malformations and intra- 
uterine diseases of the organs of respiration or circulation, such 
as defective development of the lungs, hernia of the diaphragm, 
hypertrophy of the thyreoid gland, pleural effusions, syphiloma 
of the lungs, acquired bronchial catarrh, bronchitis, and pneu- 
monia. Or anomalies of the nervous system may exist, such 
as hemorrhage or some other injury of the respiratory centre, 
and cerebral pressure from effusion, besides intrauterine mal- 
formations. Or, finally, the baby may be premature, with 
feeble muscles and soft bones. 

The treatment resembles much, or is identical with, that of 
genuine asphyxia. Respiration must be insisted upon. Warm 
and cold baths, cold affusions in the warm bath, swinging, beat- 
ing, and electricity come each in for their share in the treat- 
ment. The baby must be made to cry, or it will perish. This 
indication is particularly urgent in the acquired cases of ate- 
lectasis which result from bronchitis. There the small 
bronchial tubes are filled with a viscid sticky mucus, which 
must be removed. This is a condition not peculiar to the quite 
young only; it is as well met with in older babies suffering from 
bronchitis, particularly when in a condition of ill-nutrition and 
general debility. In them, the closing of the nose and mouth 
for from four to eight seconds will so saturate the respiratory 
centre with carbonic acid as to elicit deep and forcible inspira- 
tion immediately. It is an effective method, and not cruel 
because it is successful. 

The babies should be fed conscientiously. (See Chapter I.) 
As many are suffering from inanition, this requires close at- 
tention. They should have plenty of water, warm or hot, with 
from one to four drachms of brandy through the twenty-four 
hours, aqua camphorae, a few drachms; perhaps, as suggested 
above, nitroglycerin. Hot injections into the rectum will 
stimulate the nerves and fill the blood-vessels. The infant 



96 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

must be carried about, its position in bed changed from time 
to time, and its skin be kept warm according to the methods 
detailed before.* Even the most desperate-looking cases, with 
shallow respiration, and cyanosis of the skin and mucous mem- 
branes, may recover when the attendants are as persistent as 
the morbid condition is dangerous. 

D'Outrepont saved a newly-born of thirteen inches in length 
and one and a half pounds in weight, Kopp one of eleven 
inches and two pounds, Eedman one of thirteen inches and a 
pound and three and a half ounces, Ahlfeld one that was born 
in the twenty-ninth week of utero-gestation, measured fifteen 
inches (thirty-nine and a half centimetres), and learned how to 
suck after a few weeks; and another one that had the same size 
of fifteen inches and a weight of forty-eight ounces (fourteen 
hundred and fifty grammes) when five weeks old. It also took 
the breast afterwards. Several infants of less than three 
pounds at birth I have saved myself, nor are similar cases quite 
rare in the literature of the subject. 

J. H. Moore published in the Philadelphia Reporter of April 
17, 1880, the case of a foetus born before the end of the sixth 
month of utero-gestation — length nine inches, weight one and 
a half pounds — that cried after thirty minutes, but did not 
move. Fifteen months afterwards the same foetus is said to 



* It is this condition, in which Crede's, WinckePs, and Tarnier's ap- 
paratuses {couveuse) have triumphed over great difficulties, and mainly 
in premature babies. Holt's apparatus is simple, practical, and inex- 
pensive. A large metal incubator, devised by Mr. John P. Putnam 
and Dr. Rotch, of Boston, in which the baby lies upon a water-bath and 
is heated by graduation from all sides, was described by Dr. H. D. 
Chapin in Archives of Pediatrics, May, 1897. Still, any box or bed, 
with hot bottles and stones, or a box with double walls filled in with 
hot sand, or a bed with hot flannel, or cotton, or the hot register, or 
anything the good-will and ingenuity of the practitioner will supply, 
will answer the purpose. At the same time the air admitted to the 
lungs must be cool and pure. 



TREATMENT OF THE NEWLY-BOEN. 97 

have commenced to walk, and to have weighed nineteen 
pounds. 

3. Kephalhcematoma. 

The hemorrhage between (mostly) the parietal bone and its 
pericranium is usually the result of pressure by the lower seg- 
ment of the uterus, not always during protracted labor, or by 
the forceps. Occasionally, however, kephalhsematoma is ob- 
served after breech presentation also. Predisposition is caused 
by the deficient development of the external layer of the cranial 
bones and the shallowness of the indentations in which the 
blood-vessels are running, the thinness of the vessels, and the 
mobility of the integument. It is circumscribed, does not 
spread beyond a suture, fluctuates, and begins, after a few days, 
to be surrounded by an osseous ring, the result of the formation 
of new bone from the raised periosteum. It grows in size for 
some days, then remains stationary, and is gradually absorbed 
within from six to twenty weeks. After this time the bone is 
thickened, but absorption of the newly-formed osseous tissue 
will take place in most cases. In exceptional cases only a per- 
manent thickening will be noticed in later life. 

In some cases there is an internal kephalhgematoma as well. 
It consists in a hemorrhage between dura mater and cranium, 
and may lead to all the consequences of intracranial hemor- 
rhage (apoplexy of the new-born), — viz., convulsions, paralysis, 
death, or meningitis, cystic degeneration, etc. There may be 
no contiguity between the external and the internal hematoma. 
Still, many cases of the external form will extend directly into 
the cranial cavity through a congenital fissure in the bone. 

The treatment is forestalled by what has been said of the 
spontaneous absorption of the extravasation. No treatment is 
required. The swelling must be left alone. The bony thick- 
ening will also get well in the course of time. It is impor- 
tant to insist upon this expectant treatment, because the at- 
tendants will often not appreciate the absolutely benign nature 
of the large tumor. 

7 



98 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Meddlesome practitioners have tried compression. If there 
be any communication with the cranial cavity, this procedure 
may become dangerous by blood being forced into the interior. 
Ointments have been recommended "to make believe/' for the 
purpose of quieting the anxiety of the family. Puncture has 
been resorted to. If made at an early period, it will facilitate 
new bleeding; in many a case it has been known to produce 
suppuration, though the operation was believed to have been 
aseptic. Incision is still more reprehensible. It is not per- 
missible except in those cases which have terminated in suppu- 
ration through previous maltreatment. Then a large incision 
and thorough disinfection are indicated, and will be followed 
by a relief to pain, redness, and fever. Puncture, aspiration, 
or incision may perhaps be necessary, even without suppura- 
tion, in one of two conditions: firstly, the tumor may be so 
large as not to undergo absorption for many weeks, and to en- 
danger the bone, which may become necrotic; still, I have not 
seen such a case these twenty years; secondly, in a case of 
complication with apoplexy, aspiration may be capable of al- 
lowing some of the internal extravasation to escape. 

Other indications for the treatment of this internal kephal- 
hsematoma are suggested by asphyxia or other symptoms which 
depend on disturbed innervation. The antiphlogistic treat- 
ment will be confined to cold or cool applications only. The 
consecutive paralysis demands an appropriate treatment, the 
results of which will be mostly questionable, and depend upon 
the amount of extravasated blood, of tissue destroyed or com- 
pressed, and consecutive changes in the nerve-centre. Surgi- 
cal interference, particularly when there is depression of bone, 
was recommended by Jenkins, who reported a successful case. 

4. Hcematoma of the Sterno-Cleido-Mastoid Muscle. 
The fragility of the foetal blood-vessels and some injury 
experienced by the muscle during parturition give rise to a 
hemorrhage about or above, seldom below, the middle part of 



TREATMENT OF THE NEWLY- BOKN. 99 

the long muscle. When observed the tumor has the size of a 
hazel-nut or more; it is spherical, circumscribed, and rather 
hard. The latter condition is due to the secondary inflamma- 
tion of the torn muscular fibres. This occurrence is not at all 
very uncommon. Even in older children, mainly in kite-flying 
boys, who suddenly strain either of their sterno-cleido-mastoid 
muscles, the same hematoma and myositis are observed. 

When observed at an early period the local application of 
ice may reduce the bleeding. For a week, after ceasing the 
employment of ice, small pieces of cloth moistened with cold 
water will check the secondary inflammation to a certain ex- 
tent. Very gentle massage should be employed. During all 
this time the head must be kept immovable, — best perhaps by 
carrying the baby on a hair pillow large enough to support 
the whole body, head included When the tumor has time to 
become hard, it may last for years; when it is large, it may give 
rise to torticollis. Then gentle stretching and massage, the 
application of a mild galvanic current, and the inunction of 
an absorbable ointment of iodide of potassium may be tried 
to advantage (iodid. potass., aq., aa 1; adip. suill., 2; adip. 
lanse hydros., 6-8). 

5. Sclerema. 

The induration of the connective tissue of the newly-born 
known by that name consists of a serous infiltration of, and 
under, the skin, begins generally in the lower extremities, and 
spreads over the whole body with the exception of the chest. 
The surface is apt to be slightly hypergemic in the beginning, 
and then turns yellowish and quite pale. Eespiration is shal- 
low, nursing feeble, secretion of meconium and urine scanty, 
sensibility diminished, the pulse slow (60-75), accelerated only 
towards the fatal end, and temperature reduced much below 
the normal, even to 90° F. and less. Recovery takes place but 
very rarely. Even those who suffer from a slight attack only 
are liable to perish of pneumonia after two or three weeks. 
Many of the infants are prematurely born, exhibit defective 



100 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

innervation, possibly resulting from foetal brain-disease, or 
suffer from some cardiac affection. 

The patient must be fed from a spoon or dropper and by 
the rectum. Food should be warm, rectal injections hot. Al- 
coholic stimulants may be given in the shape of brandy or 
whiskey, four to six drops every half -hour; also a drop of tinc- 
ture of digitalis every hour or two hours, and aqua camphorse, 
ten drops every hour. Massage with oil or lanolin, com- 
mencing at the periphery, gentle but persistent with the thor- 
oughly warmed hand, or through a warmed cloth, will improve 
circulation, and probably absorption, to a certain extent. 
Maybe, also, passive movements, practised gently but per- 
sistently, and extensive (general) galvanization of the surface 
will serve the same purpose. The infant must be kept warm 
near a stove or furnace register, provided the head can be kept 
away from it and the air-supply for the lungs be kept up at a 
moderate temperature. Otherwise hot stones, hot sand, hot 
bottles, must be distributed, well covered, through the bed at 
a safe distance. Frequent bathing in salt-water of at least 
100° F., with constant friction and massage in the bath, will 
prove as beneficial as the bad or very doubtful prognosis will 
permit. 

6. Bathing. 

The first bath of the newly-born, and bathing of infants in 
general, demand great caution. For the temperature of the 
young has its peculiarities. Immediately after birth it is apt 
to lose- a degree (F.) or more, in consequence of defective cir- 
culation and respiration and of the great difference in the 
baby's surroundings before and after birth. A feeble new- 
born requires more time before its temperature rises again to 
a normal standard. That is particularly so in regard to the 
skin. Thus it is that the thermometric measurements when 
made in the axilla are as deceptive in the feeble young as they 
are apt to be in adipose adults, with their insufficient super- 
ficial circulation. 



TREATMENT OF THE NEWLY- BOKN. 101 

To a certain degree the cool air of the room has the tendency 
of reducing the surface temperature of the newly-born. When 
moderate, the sudden change acts favorably by inciting reflex 
action, but a considerable and continued reduction of tempera- 
ture must have a dangerous influence at a time when the func- 
tions of the body are not yet regulated. 

In Lassar's experiments, when an animal after recovering 
from albuminuria got exposed to a cold temperature, the same 
condition returned. Eabbits thus exposed, without or after 
depilation, suffered from interstitial inflammations of liver, 
lungs, heart, and neuroglia. The blood-vessels of liver and 
lungs became enormously dilated, the arteries filled with 
thrombotic masses, and leucocyte emigration was marked round 
the smallest veins. When the animal was pregnant, even the 
liver and other organs of the foetus were found to be inflamed. 
This is exactly what clinical experience has taught every ob- 
server of every generation, in spite of modern contradiction. 
Thus I have observed a sudden return of the morbid symptoms 
in three persistent and protracted cases of hemoglobinuria 
after every exposure to cold, and particularly to cold and moist 
air. 

Therefore the newly-born babe should not remain uncovered 
for any length of time. The nurses who spend — with more 
pedantry, emphasis, and self-consciousness than intelligence — 
much unnecessary time in oiling and soaping and washing and 
bathing, turning this and that way, drying the surface, wrap- 
ping the navel, applying the bandage, and dressing the newly- 
born in fineries, in which it finally returns to its mother's 
bed or to its crib shivering with a cold nose and blue feet, are 
not infrequently the causes of ill health or death. In a case 
recently seen, the pneumonia of the newly-born was un- 
doubtedly due to the fact that the baby was neglected while 
both physician and nurse were engaged about the fainting 
mother. Craig must have seen many such cases, for with him 
"no baby is ever washed, dressed, fed, tied up, the cord is not 



102 THERAPEUTICS OE INFANCY AND CHILDHOOD. 

wrapped up, but the infant is anointed with fat and wrapped 
in flannel the first twenty-four or thirty-six hours." Similar 
advice has been given repeatedly. 

The bath of the newly-born must not be hot. A single mid- 
wife in Elbing lost ninety-nine babies out of three hundred 
and eighty, of trismus. Through all her life she had estimated 
the temperature of the bath by trying it with her uncovered 
arm. She lost her temperature sense after a while, as was 
found by a judicial investigation, and the babies their lives. 
Still, the bath ought not to be less than 90° F., nor ought it 
to be much cooler through a number of months, in spite of a 
French author's opinion, who says that the epidermis becomes 
macerated by warm baths; that babies who are getting bathed 
grow "pale, soft, and flabby and eczematous," and proves the 
correctness of his position by his zoological discovery that "no 
other mammalia take a warm bath regularly." * 

The proportion of the surface to the cubic mass of the 
human body is larger in an infant than in an adult, and the 
number of peripherous nerve-ends and capillaries relatively 
larger. Thus there is a greater liability to reflex symptoms 
depending on exposure in spite of the low degree of nervous 
irritability in the newly-born during the first few weeks. , That 
is why a protracted cold bath is not well tolerated even by older 
infants; but, also, why tepid or cold bathing or packing ex- 
hibit a very much more rapid effect in the young than in the 
old. For both the reduction of temperature and the reflex 

* To the general rule implied in the above remarks on the necessity 
of bathing in warm water only, according to which the body of the 
newly-born infant is to be kept warm, the head forms an exception. 
Artificial heat and feather pillows ought to be avoided. A soft hair 
pillow is preferable, or a quilt lined with a layer of cotton. When- 
ever it is necessary to employ a soft head-rest, a feather pillow may 
be covered by a bed-sheet folded up to the size of the pillow and 
fastened to its corners by safety-pins. Air-cushions ought to be in 
more common use than they are. 



TREATMENT OF THE NEWLY-BORN. 103 

effect do not depend on the weight of the body, but on the 
extent of the conducting and radiating surface. 

When the baby is six months old, particularly during the 
summer months, the warm bath is to be succeeded by washing 
and friction with tepid and, later on, with cold water. When 
washing is substituted for bathing, water may be selected of 
a lower temperature, inasmuch as but a part of the surface is 
exposed to its influence at one time. When the bath, in the 
course of time, is gradually made cooler, friction of the skin 
during bathing stimulates its action. In pathological condi- 
tions, when cool or cold bathing is resorted to for the purpose 
of reducing an abnormal temperature, this aim is always and 
easily reached as far as the surface is concerned. But to ac- 
complish the same end for the whole body, it is necessary that 
the skin should retain its vitality and lively circulation. 
Unless that be so, the internal temperature may remain un- 
changed, or even rise while the surface is cool. In such a case, 
which must be ascertained by taking the rectal temperature, 
the cold bath ought to be followed immediately by a hot one 
for the purpose of restoring the surface circulation. In this 
way the reduction of temperature aimed at by the administra- 
tion of a cold bath may finally be accomplished by hot water. 
In less urgent cases the warming of the extremities and of the 
general surface by dry heat may suffice to restore the warmth 
of the surface. At all events, a cool or cold bath after which 
the feet do not become warm at once is dangerous. 

7. Mamma. Mastitis. Perimastitis. Angioma. 
Since the time of Menard, Scanzoni, and Guillot, the secre- 
tion of the mammary gland of the newly-born has been the 
subject of frequent investigations by clinicians, chemists, and 
physiologists.* It is mostly found towards the end of the first 



* Jacobi, in Gerhardt's Handb. d. Kinderkrankh., 1st vol., 2d part, p. 
39, of the 2d ed. 1882. 



104 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

week, and resembles very much the milk of the mature woman, 
in the mammae both of the male and female infant. The 
superficial milk-ducts are obstructed with epithelium; the 
interior ones are dilated in many places and filled with a cu- 
boid epithelium and a liquid which resembles colostrum. This 
secretion may be absent, but it is frequently found in prema- 
ture or still-births, though the mammas be but rudimentary. 
The dilatations will increase in size for weeks, and begin a 
retrograde development as late as the middle of the first year 
of life. 

The tendency to epithelial elimination, which is a peculiar 
feature in the newly-born, and which is so commonly observed 
in its skin, mucous membranes, sebaceous follicles, and kid- 
neys, appears to be very marked in the mamma of the newly- 
born. This discovery of Epstein's renders the subject of our 
discussion very much clearer from an etiological point of view. 

The swelling and secretion of the gland may last a week or 
two when undisturbed. After it has been squeezed out ever 
so gently, a new secretion will be invited and continue five or 
six weeks. Thus pressure of any kind should be avoided. It 
is barely possible that it may not be injurious, and that a gentle 
inunction of warm oil, which is so commonly used, may do no 
harm. But as a rule every sort of pressure occasions an attack 
of inflammation and, maybe, suppuration. Though an abscess 
be ever so small it is sufficient to destroy forever all or a part 
of the mamma, — a serious misfortune in a female. A swelled 
mamma must be left alone. Applications of cool or warm 
water, the cloth being well pressed out and covered with oil- 
silk and cotton, or flannel, or of a mild lead-wash, will answer 
well. Also applications of iodide of potassium dissolved in 
glycerin, one part of the former in two or five of the latter, 
which are repeated every few hours. Extract of belladonna 
may be added to advantage. When suppuration could not be 
avoided, the incision must not be delayed. It ought to be 
made at the greatest possible distance from the nipple, directed 



TREATMENT OF THE NEWLY-BORN. 105 

towards the nipple, so as not to cut the main milk-ducts, and 
treated antiseptically. Indurations remaining behind require 
frequent and gentle inunctions of an iodoform ointment (iodo- 
form, 1.0; ol. bergamot, 2 drops; adip. suill., 6.0-8.0), or iodo- 
form collodium, to be applied with a brush twice every day 
(iodof., 1; collod., 10-20) in such a manner that only those 
scales of the application which are peeling off from the skin are 
removed before a new layer is applied over the dried-up pre- 
vious application. No collodion should be employed as long as 
there is the slightest secretion from the surface, or from a 
wound. In place of the iodoform iodide of potassium may 
be used. A very mild galvanic current of from two to six ele- 
ments, conducted through the induration by means of soft 
sponge electrodes moistened with salt-water, has rendered me 
good service in many cases. 

Perimastitis, the inflammation of the surrounding connective 
tissue, may occur primarily, but is mostly the final result of 
traumatic mastitis. It is liable to grow dangerous, unless in- 
cisions are made early and treated antiseptically, with great 
care. I have met with not a few cases in which the suppura- 
tion of the connective tissue was very extensive, spread over 
a large surface, undermined the skin of the chest, axilla, and 
back, resulted in gangrene, erysipelas, or sepsis, and terminated 
fatally. Antiseptic solutions (applications, injections, irriga- 
tions) must be used frequently, but ought to be mild. Carbolic 
acid should be avoided, for infants are easily poisoned by it. 

The mamma ought to be examined for angiomata in every 
baby, whether there be mastitis or not. Nsevi are by no 
means rare in this neighborhood, and ought to be destroyed at 
once, either by the application of fuming nitric acid when 
superficial or by the actual cautery (red-hot iron, galvano- 
cautery, or thermo-cautery) when deep-seated or genuine vas- 
cular tumors, for they are liable to grow rapidly, and prove 
dangerous to the female. 



106 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

8. Treatment of the Cord. 

The indications for the application of the ligature, and 
thereby the complete interruption of f cetal circulation, appear 
to vary in the practice and teachings of the obstetricians. 
When the baby has cried a few times, the majority apply the 
ligature and cut the cord. Others insist upon waiting for the 
collapse of the cord produced by that of the vein, while the 
arteries are still pulsating, and some will wait for the disap- 
pearance of the arterial pulse. A few facts may be remem- 
bered for the purpose of guiding the practitioner in individual 
cases, for the amount of blood entering, or retained in, the 
body of the infant is by no means an indifferent matter. 

If the ligature be applied after the cessation of the umbili- 
cal pulsation, there are still six ounces of blood (one hundred 
and ninety-two grammes, according to Zweif el) in the placenta. 
If the latter be compressed by Crede's procedure that amount 
is reduced to three ounces (ninety-two grammes). Thus the 
difference between the two procedures means a difference of 
three ounces of blood in the circulation of the newly-born, 
which is an enormous addition to the usual quantity of blood, 
which in the infant slightly older is but little more than five 
per cent, of the total weight of its body. After all, it appears 
that the deferred separation of the baby, when poorly devel- 
oped and pale, and the admission of more blood to its system, 
is deserving of recommendation; while, on the other hand, 
there may be an occasional indication for bleeding the infant.* 

The admission of a large quantity of blood, however, is no 
unmitigated blessing. The blood-vessels of the newly-born 
are so thin and fragile that spontaneous hemorrhages on serous 
membranes and into the nerve-centres, etc., are by no means 
uncommon under normal circumstances. It is true that the 
destruction of superfluous blood-corpuscles is very rapid, as 

* Archives of Pediatrics, March, 1888, p. 130. 



TREATMENT OF THE NEWLY- BOBN. 107 

rapid, indeed, as it is known to be after transfusion in the 
adult, but some time is required to accomplish that end, and 
during that time hemorrhages may take place, and have been 
reported by Neumann and Illing, and observed by me. This 
danger is sufficiently great to counterbalance the alleged ob- 
servation of Hofmeier, according to whom babies, after de- 
ferred separation from the mother, lost less weight and com- 
menced to increase sooner than those removed more speedily. 
However, Violet states that the former lost twenty ounces (six 
hundred and nineteen grammes), the latter but nineteen (five 
hundred and eighty-five grammes). 

Nor does Porak's observation, according to which congested 
babies exhibit a more intense degree of jaundice, lack con- 
firmation. 

If the ligature be thin, it is liable to cut through the walls 
of the blood-vessels prematurely; if too thick, it may not suf- 
fice to compress them satisfactorily. It ought to be applied at 
a distance of from one and a half to two and a half inches from 
the abdominal wall (three to five centimetres); not nearer, in 
order to avoid the effect of the immense muscular power of 
the umbilical arteries inside the abdominal cavity. A second 
ligature is placed about an inch from the first, and the cord 
cut between them. It is a good rule, which must surely be 
adhered to in every case of thick cord, to apply an additional 
ligature between the first and the abdominal wall, to avoid 
hemorrhage which may take place after the cord has com- 
menced to shrink, from the insufficiently compressed arteries. 
The abdominal end of the cord is then wrapped up in a dry 
and soft piece of linen, lint, or borated cotton, placed on the 
left side of the abdomen, and fastened, by means of a soft 
flannel bandage, which is wide enough to cover the larger part 
of the chest and all of the abdomen, so as not to slip. 

In wrapping up the end of the cord no oil or fat should be 
used. "Warmth and dryness favor mummification; moisture and 
exclusion of air, gangrene. This holds good also for the cord 



108 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

when it is separated from the living baby by an additional liga- 
ture, and in the dead. Thus, the former forensic axiom, which 
prevailed for decades after Meckel had demonstrated its fallacy 
as early as 1853, that a dry cord proved that the baby had lived, 
is absolutely worthless. Fatty substances, and moisture of 
any kind, must be avoided. Powdered subnitrate of bismuth, 
or oxide of zinc, or iodoform, or salicylic acid, one part with 
forty or twenty parts of starch, may be dusted round the inser- 
tion of the cord and over the stump daily. The latter appli- 
cation is not necessarily useless (from the point of view of anti- 
sepsis), for the separation of the cord is a gradual one, and not 
uniform through the whole thickness of the amnion and the 
three blood-vessels. 

The size of the sore stump and the rapidity or slowness of 
cicatrization depend upon the thickness of the cord, the inten- 
sity of the line of demarcation, and the reactive inflammation. 
The latter are most marked in vigorous infants. As a rule, 
the surface is dry a few days after the falling of the cord, and 
cicatrization complete within twelve or fifteen days after birth. 
This normal process is, however, disturbed by careless hand- 
ling, local irritation, and infectious influences. In these un- 
favorable cases there is a serous or purulent secretion, and 
cicatrization may be deferred for many weeks. Under these 
circumstances local treatment is required. Carbolic acid 
ought to be avoided, for the newly-born and infant are easily 
influenced by its poisonous properties. Solutions of lead, zinc, 
or alum answer quite as well as any solutions do. As I 
said, however, it is best to avoid water. I recommend the 
powders of zinc oxide, bismuth subnitrate, alum with starch, 
salicylic acid with starch, or iodoform. Such measures will 
always prove helpful; to omit them in times of prevailing ery- 
sipelas or diphtheria is unpardonable. Perchloride of iron, 
or subsulphate of iron, must not be used. Under the hard 
coagulation formed by their application over the whole wound 
secretions will accumulate, cannot escape, are absorbed, and 



TREATMENT OF THE NEWLY-BORN. 109 

produce sepsis. I have seen babies die from applications of 
iron to the umbilical stump, as I know of women dying for 
the same reason when the hemorrhages from their uteri or 
from the lacerated vaginae were maltreated in the same manner. 

9. Omphalitis. 
Inflammatory infiltration of the abdominal integuments 
which surround the stump, with swelling, pain, purplish dis- 
coloration, gangrene, or abscesses, and consecutive peritonitis, 
occurs within a few weeks after birth, and is the result of trau- 
matic or septic influences. The dermatitis requires applica- 
tions of lead-wash; tendency to suppuration, moist antiseptic 
(or aromatic) applications, such as Thiersch's solution (sali- 
cyclic acid one part, boric acid six parts, water one hundred and 
twenty-eight parts); the presence of pus, a large incision, with 
antiseptic after-treatment. Cold applications are not toler- 
ated. Bathing is painful. Any of the antiseptics mentioned 
previously will render good service. Carbolic acid must be 
avoided. Generous feeding by a wet-nurse, alcoholic stimu- 
lants (from one to two teaspoonfuls of whiskey daily), plenty 
of water, and evacuation of the bowels by injections, are the 
additional aids in treatment. The main reliance is on the local 
treatment, — viz., large incisions and antisepsis. 

10. Umbilical Gangrene. 
This is the result of an inflammatory process, mostly in a 
prematurely born baby, or one that fell sick with diarrhoea. It 
may extend inward to the intestine and terminate in perfora- 
tion. The prognosis is very bad except in the few cases in 
which there is a well-marked line of demarcation. The treat- 
ment consists in antisepsis and stimulation. 

11. Arteritis and Phlebitis. 
The former is very much more frequent than the latter. 
Arteritis is often connected with general sepsis, pneumonia, 



110 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

pleurisy, peritonitis, arthritis, and subcutaneous abscesses. 
The infection reaches the arteries from outside through the 
lymph circulation, begins in the connective tissue surrounding 
the vessels, and attacks the adventitia first. To discover the 
source of infection is sometimes very difficult; in his experi- 
ments Budin succeeded in forcing septic material through the 
cord from beyond the umbilical ligature. Pus can seldom be 
squeezed out of the arteries, and the diagnosis is sometimes 
made at the autopsy only. The disease begins often before 
the complete separation of the cord, absorption taking place 
through the cord, which dries and shrinks irregularly, and 
admits poison through the newly-formed cuts or fissures. 

The treatment is indicated by the causes, which are self-in- 
fection from a putrefying surface, infection by soiled fingers, 
cloths, baths, applications of any kind, the contact with a septic 
mother, or the contact with anything septic, — for instance, the 
pus of ophthalmo-blennorrhoea, or the decomposing lochial 
discharges of a healthy woman. Thus the treatment is mostly 
preventive. The scissors, cloths, and sponges used for the 
newly-born must be aseptic. The baby must not be in the 
mother's bed, and must be attended before the mother on the 
days following her confinement. The hands touching the 
baby's body must be carefully cleaned and disinfected many 
times a day, the cord and umbilical wound treated as detailed 
before. They should be kept tied up conscientiously. There 
should be no possible contact between them and the faecal dis- 
charges, be these ever so normal; if there be diarrhoea the 
greatest caution is required, for the danger of infection is im- 
minent. If the mother suffer from puerperal sepsis the baby 
may be permitted to nurse, but should be kept in another 
room constantly and carried into the presence of the mother 
for the purpose of nursing only, and contact avoided. The 
internal treatment is identical with that advised in omphalitis 
and gangrene. 

The symptoms of phlebitis differ sometimes from those of 



TREATMENT OF THE NEWLY-BORN. Ill 

arteritis in this, — that there is more peritonitis of the hepatic 
region from the beginning, more epigastric meteorismus, more 
icterus. Now and then pus may be obtained by gently squeez- 
ing along the course of the vein. The infection is either di- 
rect, through the vein, in which an ulcerous process is some- 
times found half an inch or an inch above the navel, or also 
through the lymph-current in the surrounding connective 
tissue and the adventitia of the vessel. The treatment cannot 
differ from that of arteritis. Eecovery is possible when the 
absorption of the poison has not been very copious, or elimina- 
tion progresses with absorption at an equal rate. A female 
baby of less than three pounds, in my experience, exhibited no 
other source of septic infection but a slight erosion or ulcera- 
tion of the umbilical stump, with hardly any secretion. She 
recovered, though the process extended to the end of the second 
week, with temperature reaching sometimes 103° F. 

12. Puerperal Sepsis. Acute Fatty Degeneration. Epidemic 
Ho3moglobinuria. 

The treatment outlined in the last chapters is to a great 
extent also that of the puerperal sepsis of the newly-born con- 
tracted before birth, or immediately after, from the mother 
(umbilical changes, fever or collapse, peritonitis, pleuritis, 
pneumonia, meningitis, jaundice, diarrhoea, — in fact all the 
possible symptoms of septico-pyoemia). It takes more than 
"an ounce of prevention;" but, after all, prevention is all that 
can be done. Eecovery is a bare possibility only. 

Acute fatty degeneration of the liver, heart, and kidneys, also 
of the lungs and the intestinal villi, with multiple hemorrhages, 
jaundice, cyanosis, vomiting, and diarrhoea, does not seem to 
get well. Almost the same may be said of epidemic hemo- 
globinuria (Winckel), which exhibits the same symptoms, to 
which is added the presence of haemoglobin in the urine. It 
is of a brownish-red color and contains no blood, but renal and 
vesical epithelia, casts, and cocci. 



112 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

13. Umbilical Hemorrhage. 

This may take place from the arteries, either before or after 
the separation of the cord. Its treatment is either mostly 
preventive, or the indications become so clear in every indi- 
vidual case that it becomes easy to fulfil them. Though the 
pulmonary aspiration and the great contractility of the mus- 
cular layers of the arteries render a hemorrhage difficult, 
even when no ligatures were applied, an insufficient develop- 
ment of those muscular fibres, or the presence of asphyxia or 
atelectasis, or a pneumonia, may produce a disposition to bleed. 
That is why the ligature, or ligatures, should be tied accurately. 
In such cases of bleeding it may become necessary to apply 
an additional ligature. The arterial power being greatest in 
the abdominal cavity and near the umbilical ring, the cord 
must not be cut near the body. Two ligatures, as described 
above, are a fair preventive. Tight abdominal bandages im- 
pede circulation, and should be avoided. When the cord is 
cut too short, or torn off, it may be impossible to secure the 
vessels; in such cases two long harelip needles should be run 
through the abdominal wall, near the vessels, crosswise, and a 
strong ligature tied underneath them. The same procedure 
may be resorted to when the hemorrhage takes place after the 
separation of the cord, either from the blood-vessels or from 
the slowly-healing surface, in consequence mostly of incon- 
siderate handling. When the hemorrhage ceases, a moderate 
compression of the wound, which is covered with iodoform or 
the salicylic acid and starch-powder, and borated cotton, by 
means of a bandage, will answer well. In obstinate cases anti- 
pyrin in a twenty or fifty per cent, solution should be applied. 
No iron. When the surface is granulating, the proliferations 
may be touched with the solid stick of nitrate of silver. 

All of such cases yield a better prognosis than those result- 
ing from haemophilia, congenital syphilis, general sepsis, or 
acute fatty degeneration. In these conditions the blood co- 



TREATMENT OF THE NEWLY-BOEN. 113 

agulates with even greater difficulty than that of the healthy 
new-born, and not infrequently all attempts at stopping the 
bleeding are liable to prove futile. The ligation of the whole 
mass is often unsuccessful because the stitch-channels will also 
bleed; chemical styptics are too often useless; plaster of Paris 
has sometimes proved successful, and the actual cautery has 
proved advantageous in a few cases. But the majority of such 
cases terminate fatally. 

If the case be one of syphilis, subcutaneous injections of 
corrosive sublimate should be tried (see pp. 75, 114). A sugges- 
tion of Bienwald's, who applied fresh coagulable blood of a 
healthy person to the bleeding wound of a hsemophilic patient, 
with the result of causing coagulation and insuring recovery, is 
here reported for what it may be worth or not. A. E. "Wright 
claims a styptic effect of a solution of fibrin ferment and 
chloride of calcium. 

11. Icterus. 

A certain degree of yellowish discoloration of the skin is 
the result of the normal changes of hasmatin deposited in the 
skin during the rapid transition from foetal to postnatal cir- 
culation. When by retarded separation of the newly-born 
from the mother, and compression of the placenta, the amount 
of blood in the circulation of the infant is unduly increased, 
this form of hsematogene jaundice is rather more developed. 
The simplest form of hepatogene icterus is produced by the 
sudden diminution of the blood circulating in the vessels of the 
liver, which encourages the exosmotic transition of bile from 
the bile-ducts into the adjoining blood-vessels. All of these 
forms of jaundice require no treatment. Duodenal catarrh will 
produce, in rather rare cases, icterus in the newly-born, as it 
does in advanced age. That is why the feeding and the diges- 
tion of the baby must be carefully watched, and the air pure. 
The routine administration of syrup of rhubarb is a mistake on 
the part of the female busybodies which should be discouraged. 
Maybe some of them can be taught that acid cow's milk and 

8 



114 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

indiscriminate feeding in general, and exposure, tight band- 
aging, and cold feet, can do still more harm than their medi- 
cines. Icterus resulting from congenital obliteration of the 
large biliary ducts, or from congenital cirrhosis, or from acute 
fatty degeneration, or from epidemic hemoglobinuria is in- 
curable. Icterus during septic infection is a bad symptom, 
and rarely terminates otherwise than in death. Icterus de- 
pending on congenital syphilis of the liver is grave, but I have 
met with several cases that recovered. A thorough and en- 
ergetic antisyphilitic treatment is the only safe-guard in such 
cases. It may prove unsuccessful, however, because the syph- 
ilitic process of the connective tissue is not confined to the 
liver, but extends to the rest of the organs. Mercury must be 
administered for a long time, a twentieth or a twelfth of a 
grain of calomel three times a day; careful inunction of a 
scruple of blue ointment daily; or one-thirtieth of a grain of 
corrosive sublimate in a one-fifth of a per cent, solution of dis- 
tilled water for subcutaneous injection daily. In the begin- 
ning of the treatment two of these medications may be com- 
bined, or one of these together with the internal administration 
of from three to five grains of iodide of potassium daily, in 
three doses, which are given after meals. The internal ad- 
ministration of the bichloride of mercury is also well tolerated; 
one one-hundredth of a grain may be given in a teaspoonful of 
water, or food, every two or four hours, and continued many 
weeks. 

15. Melcena Neonatorum. 

Hemorrhage from the bowels (more frequent than from the 
stomach) occurs on the second or third day of life; also later 
within the first week. Syphilis, acute fatty degeneration, epi- 
demic hemoglobinuria, and sepsis of other varieties, — also 
asphyxia, — cause a predisposition; also pulmonary obstructions, 
cardiac disease, and a widely open ductus Botalli with consecu- 
tive intense congestion. A thrombus emanating from the 
latter, or one coming from the ductus venosus Arantii (Landau) 



TREATMENT OF THE NEWLY- BORX. 115 

may cause an embolic ulceration of the stomach or duodenum. 
The blood is fluid or coagulated, rather black, like that of 
haematemesis in advanced age. It is, however, mixed with the 
food and rather reddish when it was swallowed while nursing. 
A mistake in diagnosis may happen when blood is swallowed, 
during an operation on the lip or cheek, or during an epistaxis 
resulting from an injury. A single observation of the latter 
kind was published lately, and generalized as the cause of 
melsena. 

The quantity of blood evacuated from the bowels is some- 
times enormous, particularly in view of the fact that the 
weight of the blood in the body of the newly-born amounts 
to little more than five per cent, of the weight of the baby. 
The cases complicated with vomiting are the worst. These 
result mostly from the presence of ulcerations in the stomach 
and duodenum. Competent respiration and an aseptic um- 
bilical wound are the best preventives. Babies should cry 
from time to time to stimulate and strengthen both circula- 
tion and respiration. The treatment consists in applications 
of ice to the epigastrium, while the limbs are kept thoroughly 
warm by artificial means. Tincture of chloride of iron may 
be given in drop doses. Food is to be given at a low tempera- 
ture. Rectal alimentation is mostly useless because of the fre- 
quency of discharges. In a desperate case of anaemia and 
collapse the subcutaneous injection of a sterilized salt-water 
solution may prove helpful. I could not convince myself of 
the usefulness of subcutaneous injections of ergot. 

16. Trismus and Tetanus. 
Its prognosis is not quite so bad as it was believed to be, 
formerly. Now and then recoveries have been reported, and 
I have seen them myself, though the number of cases observed 
by me have not been very numerous. The prognosis is better 
when trismus appears at a later period after the separation of 
the cord than usual, and when its course is protracted. Cases 



116 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

lasting more than five or six days are rather promising. Such 
as set in early and exhibit a high temperature (106° and more, 
up to 111° F.), with disturbances of respiration and great in- 
anition, are bad. As a preventive, it has been proposed to re- 
move women, for the time of their confinement and recovery, 
from districts where trismus is endemic. At all events, the 
greatest care should be taken of the umbilical wound, through 
which the invasion of the specific bacillus takes place. Some 
of the cases are mild, — that is, not fatal. Maybe they are those 
only which are due to excesses of temperature, high or low, — 
there are those of "rheumatic" origin, — or to lesions of the 
brain or medulla oblongata. Food must be introduced through 
the rectum or the nose, and as much water as possible. For 
days after no food could be swallowed when introduced into 
the mouth, the patients were sometimes able to swallow what- 
ever was thrown into their pharynx. By means of a medicine- 
dropper or a small teaspoon fluids may be poured down. Medi- 
cines must be administered subcutaneously, atropiae sulphas 
in doses of one one-thousandth or one six-hundredth of a grain 
a number of times daily; curare, one-fiftieth or one-thirtieth; 
extract of calabar, one-half of a grain. A few of my cases got 
well with chloral, mostly per rectum, in doses of from one to 
five grains from six to ten times a day, and occasional inhala- 
tions of chloroform. High temperatures may be influenced 
by antipyrin or antifebrin, combined with whiskey or brandy. 
Bathing is contraindicated because the baby bears no handling. 
Even applications of cold water for the purpose of reducing 
high temperatures should be local only, and made without 
turning or tossing the patient. 

All this medication is not rendered superfluous by the sub- 
cutaneous administration of the antitoxin, first introduced by 
Tizzoni and Cattani. They should be combined. One case 
out of four of Escherich's recovered* under the use of three 

* It is an aseptic serum in a desiccated state. ". . . According to Merck 
it is to be dissolved in distilled water in the proportion of ten parts by 



TREATMENT OF THE NEWLY-BORN. 117 

doses of three decigrammes (five grains) each injected in the 
course of two days. The chemical poison evolved out of the 
invading bacilli is not absorbed at once; the invasion is more 
or less persistent and should be stopped in the admitting wound 
(mostly the umbilicus) by the actual cautery, or by applications 
of tincture of iodine, or of a one- or two-per-cent. solution of 
iodine trichlorid, or a one-half of a per-cent. solution of potas- 
sium hydrate, or one-twentieth-per-cent. dilution of hydro- 
chloric acid, or a one-per-cent. dilution of kresol (Sahli D. Med. 
Zeit., No. 11, 1896). Similar rules are given by the Health 
Department of New York. Of the antitoxin, twenty cubic 
centimetres are a dose for an adult; accordingly, one cubic 
centimetre seems to be appropriate for the newly-born. 
(Archives of Pediatrics, July 1, 1897.) 

17. Blennorrhcea. 
Blennorrhceic conjunctivitis may be prevented by repeated 
disinfectant injections into the vagina of the woman in labor. 
For that purpose a solution of three parts of carbolic acid in 
one hundred of water, or one of bichloride of mercury in one 
or two thousand of water, are sufficient. After the newly-born 
has been bathed, a few drops of a two-per-cent. solution of ni- 
trate of silver, or a one-twentieth of a per-cent. solution of bi- 
chloride of mercury, are applied to the cornea. When the 
disease is established, both eyes are affected in most cases. 
When but one, the healthy eye should be covered with a disin- 
fecting lotion and borated cotton, and its infection by sponges, 
towels, water, and fingers guarded against with the greatest 
care. The diseased eye must be kept scrupulously clean by 

weight to one of the desiccated serum. ... It is imported in small bottles, 
and it is recommended to inject the contents of half a bottle for a first 
dose" (for an adult), "while the remainder is divided into four equal 
quantities and injected at intervals depending on the result of the first 
dose and the symptoms of the disease." (James Stewart, in Loomis 
and Thompson, "A System of Practical Medicine," vol. i. p. 943.) 



118 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

pouring tepid water over the cornea, or (and) removing the 
pus by means of small pellets of borated cotton. To succeed 
in this the upper and lower eyelids must be turned out. This 
is not always easy, and is never satisfactory unless the cornea 
becomes perfectly visible during the manipulation. Once a 
day the application of a mitigated stick of nitrate of silver (nit. 
arg., 1; nit. sod., 2) is useful. It may be substituted by a two- 
per-cent. solution of nitrate of silver in water. In both cases 
the diseased surface should be washed with a mild solution of 
table-salt afterwards, and ice-cloths, small and as dry as pos- 
sible, applied every ten minutes or oftener. When the cornea 
is ulcerated, a few drops of a solution of sulphate of atropia 
(1 to 200) may be instilled several times daily. 

But lately G. Schallern experimented on the eyes of nine 
hundred and seventeen new-born, in the obstetrical clinic of 
Gottingen. Two babies only became affected, and on the eighth 
day only; all were saved. The slight irritation following (in 
some cases) the application of the two-per-cent. solution of 
nitrate of silver passed by without any injury. When that irri- 
tation is observed, no new application should be made- in the 
next twenty-four or thirty-six hours. (Archiv f. Gynak., 1897, 
p. 86.) 

18. Umbilical Fungus {Granuloma). Adenoma. 

The umbilical stump requires frequent inspection. Unless 
it cicatrizes speedily, granulations will spring up from its sur- 
face and form into small tumors. They are either sessile or 
pedunculated, and are apt to grow very fast. They are not sen- 
sitive, but apt to bleed. In some cases they are discovered on 
very close examination only, and may remain many years, even 
to advanced age. Exceptionally such a fungus is not, or but 
partly, the result of granulation, but consists mainly of the 
remnants of the omphalo-mesenteric duct (with unstriped 
muscular fibres, tubulated glands, and cylindrical cells) or of 
the allantois. Once it was found by Yirchow to be a sarcoma. 
Waldeyer met with some that were adeno-sarcomata. 



TREATMENT OF THE NEWLY-BORN. 119 

Usually it requires no excision, but only cauterization or as- 
tringent and antiseptic applications. Nitrate of silver may be 
used, but must be neutralized by chloride of sodium imme- 
diately. Other applications are, a drop of liquor subsulphatis 
ferri once or twice daily; the powdered subnitrate of bismuth; 
iodoform; one part of salicylic acid with five parts of starch. If 
the granuloma is large, or when it returns, it should be removed 
with the scissors, and the stump scraped off. Dry antiseptic 
treatment is to follow (subnitrate of bismuth, dermatol, aristol, 
nosophen). The persistence of the omphalo-mesenteric duct 
which presents itself as a small tumor after the cord has fallen 
off, should not be taken for a granuloma. It would be a grave 
error to treat it like one lightly, and cause a peritonitis or a 
persistent intestinal fistula. To close it a careful aseptic oper- 
ation is required. 

19. Hernia. 

Congenital umbilical hernia (exomphalus) is called a fissure 
of the median line of the abdominal wall, which is the result 
of an arrest of development. When the fissure is but small 
and the sac contains intestine only, the condition was con- 
sidered incurable. There is no reason why an operation on 
these cases, in which the abdominal defect is small, should not 
be at least as successful as those on more pronounced ones, for 
when the sac is large, containing at least a portion of the liver, 
together with intestine, the contents may be reduced and the 
cases cured. Twenty-four such cases have been collected by 
Kocher.* C. Brenz reports the case of a girl weighing two 
thousand seven hundred grammes at birth. "When the hernial 
contents had been reduced, which was accomplished with diffi- 
culty, he caught the edges of the sac by means of a pair of pin- 
cers, removed it with scissors, applied three percutaneous liga- 
tures, removed the clamp, applied the actual cautery to the 

*A. Jacobi, "The Intestinal Diseases of Infancy and Childhood," 
p. 267. 



120 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

stump, and covered it with antiseptic dressings. Both these 
and the ligatures were removed on the eighth day. The case 
proved successful, though there was peritonitis as early as 
twenty-four hours after birth. D'Arcy Power reports an un- 
successful case ("Surg. Dis. Child.," 1895). 

Acquired umbilical hernia, which contains small intestine 
and peritoneum, and is produced by a large size of the cord, 
by leanness and insufficient development of the baby, and by 
screaming, coughing, and the straining consequent upon diar- 
rhoea, constipation, phimosis, or anal fissure, demands the treat- 
ment indicated by these causes, and reduction, which is almost 
always quite easy, and retention, which is by no means so easy, 
within the abdominal cavity. The usual shape of trusses is 
unavailing, or even injurious. Whatever appliance is used 
should be larger than the aperture, and not be too hard. 
Linen or lint compresses, plates of cork, covered with linen or 
lint, may be held in position by means of a bandage, to which 
they can be fastened by stitches or pins. Knitted bandages 
are more useful than those of linen, cotton, or flannel cloth. 
Adhesive plasters are used frequently, but are generally too 
irritating on the sensitive surface of the infant. 

Incarceration and strangulation of an umbilical hernia are 
very rare, but there is on record a fair number of cases in 
which herniotomy was performed successfully on infants of a 
slightly advanced age. 

Inguinal hernia is a curable disease. When the short and 
straight inguinal canal of the newly-born becomes more ob- 
lique and the adjacent fat increases in the course of a few 
years, the rupture will disappear, provided a proper truss has 
been retained for a long time. During that period the intes- 
tines must not be allowed to protrude at all. The truss must 
be worn day and night, with the exception of such times when 
the infant is sleeping quietly. A good fit does not mean undue 
pressure. The testicle must be closely watched. It is found 
high up in the scrotum, behind the hernia. Sometimes it has 



TREATMENT OF THE NEWLY-BOKN. 121 

not descended into the scrotum, and is then mostly discovered 
in the inguinal canal. By gently pressing it downward and ap- 
plying the truss above, we not only protect it but facilitate a 
complete descensus. Mr. William Coates's (1848) appliance 
"consists simply of a skein of lamb's wool; for infants Berlin 
wool is preferable. This encircles the pelvis, one end being 
passed through the other at a point corresponding with the 
inguinal ring; the free end is carried between the thighs, and 
is fastened behind to that portion which forms the cincture. 
This simple and cheap contrivance can be worn during the 
morning and evening ablutions, and then changed for a dry 
one. No attention is required on the part of the nurse, except 
at the moment of changing." (D'Arcy Power, "The Surgical 
Diseases of Children," Philadelphia, 1895, p. 414.) 

For such cases as prove too obstinate, a radical operation 
becomes advisable, in some it is inevitable. (D'Arcy Power, 
and the special works on surgery. See also Digestive Organs.) 

20. Congenital Constipation. 
Malformations of the intestinal tract, such as strictures or 
complete interruptions, will either terminate fatally (when 
inaccessible) or require surgical treatment. The latter class 
includes imperforate anus and rectum. In these cases, the ob- 
struction being complete, we cannot speak of constipation. 
This latter condition may, however, be found to depend on an 
anatomical peculiarity which is quite frequent, and may give 
rise to mistakes in diagnosis and treatment. The colon descen- 
dens of the newly-born is quite long. The sigmoid flexure, 
which I have found to measure as many as thirty centimetres 
(twelve inches), is bent upon itself several times in the narrow 
pelvis. Thus the convolutions of the intestine will press upon 
and compress each other* to such an extent as to result in ob- 

* A. Jacobi, "The Intestinal Diseases of Infancy and Childhood," 
Detroit, 1887, p. 184. 



122 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

stinate constipation. In some extreme cases the babies died 
without or with colotomy, which was performed on the strength 
of a mistaken diagnosis. The treatment of that congenital 
form of constipation must be adapted to the anatomical con- 
dition which gives rise to it. Rectal injections alone are 
rational. They must be made daily, at least once a day, and 
continued up to the completion of the fifth or sixth or even 
seventh year. At that period the normal relations of the 
several parts of the intestine are established, the pelvis be- 
comes larger, and evacuation of the bowels easier. No purga- 
tive medicines must be resorted to, inasmuch as the obstacle is 
mechanical only. There is, however, a single indication for 
their administration, — viz., those symptoms depending upon 
constipation, which point to the absorption of intestinal toxins 
above the obstruction. Septic fever, high temperatures, and 
serious reflex symptoms — such as convulsions — may require the 
speedy evacuation of the bowels. Though such occurrences be 
rare, they should be looked for. (See "Non Nocere" in Trans. 
11th Internat. Med. Congress, or N. Y. Med. Record, May 19, 
1894.) 



IV. 

DISEASES OF THE BLOOD AND CONSTITUTION. 

1. Ancemia. 
Anemia is often the result of a hereditary predisposition, or 
it is congenital from some accidental cause. Mothers who suf- 
fered much during their pregnancies, or were delicate them- 
selves, are liable to give birth to anaemic and puny infants. Pre- 
mature infants, or those afflicted with congenital diseases, such 
as "cyanosis" or neoplasms, or smallness of heart and arteries, 
are anaemic, and apt to remain so. Another cause of idiopathic 
or primary anaemia is found in actual loss of substance by 
copious suppuration, excessive exudations in pneumonia and 
pleurisy, or by actual hemorrhages, the results of which are in 
some cases perceptible through a whole lifetime. They are 
quite frequent in the newly-born or young, in true melaena, 
haemophilia, umbilical bleeding, and sometimes even in kephal- 
haematoma; from harelip operations or ritual circumcision; 
from the prolonged losses by rectal polypi; in older children 
from epistaxis occasioned by coryza, heart-disease, or ab- 
dominal stagnation; from ulcerations in diphtheria; from 
trauma. Acute anaemia thus caused requires external and in- 
ternal styptics, the closure of wounds, the application of ice, 
and mainly when parenchymatous bleeding is obstinate, the 
external use of a twenty- or even fifty-per-cent. solution of 
antipyrin. The subcutaneous injection of fluid extract of 
ergot, the internal use of acetate of lead (hourly doses of two 
or five centigrammes (gr. ^-f ) may be given ten or twelve 
times without fear) or of liquor perchloridi ferri (five to ten 
drops amply diluted), stimulants internally, externally, and 

123 



124 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

subcutaneously, ligature around the extremities so as to com- 
press the veins, warming of the surface, transfusion of defibrin- 
ated blood, or of a sterilized salt solution (6 : 1000) are apt 
to meet the most urgent necessities. 

As far as chronic anaemia is concerned, I cannot do more 
than simply allude to its direct and indirect causes for the pur- 
pose of obtaining the indications for treatment. Among the 
former is prominent an insufficient amount or an improper 
composition of food and insufficient supply of oxygen. Poverty 
with its wants, its squalid and airless dwellings, and overwork 
in overcrowded school-rooms, are all powerful sources of wide- 
spread anaemia; they become social problems, more than merely 
medical questions. Among the indirect causes I count every 
disease of more than a temporary character; all those ailments 
which so change the alimentary digestive organs as to inter- 
fere with digestion; intestinal worms, which are sometimes 
borne without symptoms, sometimes irritate and annoy (oxy- 
uris, ascaris), sometimes, however, interfere with assimilation 
to such an extent as to cause the gravest forms of anaemia" 
(ascaris, taenia, bothriocephalus); diseases of the organs of 
respiration, circulation, and elimination (kidneys); all feverish 
diseases, and particularly the infectious fevers (scarlatina, ma- 
laria, least of all typhoid fevers, unless they result in chronic 
intestinal ulcerations) ; diseases of the lymph system (including 
what is meant by "lymphatic condition" in the writings of a 
few modern authors), the larger part of which are accessible to 
successful treatment. It is true that pseudoleukaemia, leucocy- 
thaemia, pernicious and kindred anaemias offer the same diffi- 
culties which we meet in the adult; but the many glandular 
swellings — "scrofulous" or not — permit of successful treat- 
ment, both preventive and curative. 

All of these affections, the number and names of which I 
do not care to multiply, are the more dangerous, and require 
the more dietetic and medicinal attention, the greater their 
detrimental influence during infancy and childhood, — that is, 



DISEASES OF THE BLOOD AND CONSTITUTION. 125 

during the period of growth, in which the organism has not 
only to sustain itself, but to increase steadily. The latter con- 
sideration is a very important one. It includes the necessity to 
which I have alluded in a previous chapter, not to permit a 
morbid condition, either acute or chronic, to run its full course 
without interference. A disease shortened a day, a sleepless 
night less, a dozen of diarrhoeal movements prevented, a rack- 
ing cough soothed, a convulsion interrupted, an excessive tem- 
perature relieved, are just as many prophylactic points gained, 
and as many causes of persistent anaemia mitigated in their 
dangerous influences. 

These considerations are the more weighty the younger the 
patient. For in regard to anaemia the young are in a very 
precarious condition indeed. The infant (and child) has less 
blood in proportion to its entire weight than the adult; this 
blood has less fibrin, less salts, less haemoglobin (except in the 
newly-born), less soluble albumin, less specific gravity, par- 
ticularly between the second and twelfth month of life, and 
more white blood-corpuscles. It has a specific gravity of but 
1045 or 1049 compared with that of 1055 in the adult. The 
total amount of the blood in the young is relatively small. Its 
weight, compared with that of the body in the newly-born, is 
1 : 19.5. The relative figures in the adult are 1 : 13. 

Hence it follows, from a practical point of view, that it is 
important not to permit the proportionately small amount of 
blood in an infant or child to be unduly diminished or diluted. 
That is why the subject of feeding and digestion is of such 
paramount weight in paediatrics. 

While it is a good rule to be careful in regard to the amount 
of food to be given in the beginning of a feverish disease, a 
fair quantity should be allowed after a while, provided it is 
fluid and well selected. Unless there be a contraindication in 
the condition of the stomach, a fair amount of albuminous 
nutriment (milk) should be administered. During protracted 
diseases the danger of inanition becomes imminent, still more 



126 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

in the young than in the adult. Convalescence requires gener- 
ous feeding and stimulation also, with this restriction, that the 
meals should be small and frequent, and the stomach sustained 
all the time. In this way many a case of secondary anaemia 
may be avoided. (Chapter I.) 

Babies become anaemic when their mothers or nurses have 
too little milk, or when the supply is ample but of an improper 
quality. Nursing during a subsequent pregnancy ought to be 
forbidden. It must not be continued too long, certainly not 
beyond the protrusion of the first group or groups of incisors. 
Nor must it be continued beyond the tenth month if at that- 
time no tooth has made its appearance. Many a case of anaemia 
or rhachitis will be cured by a change of such faulty diet. It 
is better for the baby to develop teeth, bone, and muscle on 
barley or oatmeal and cow's milk and beef-broth than to be- 
come rotund with cedematous fat, and anaemic on its mother's 
powerful sympathy and powerless breast-milk. Maternal love 
does not improve the breast-milk of a person with a history of 
consumption, rickets, syphilis, nervous disorders, or intense 
anaemia. Sometimes even a healthy woman has a milk which 
is not adapted to that particular baby; then another woman or 
artificial food must be preferred. The addition of barley or 
oatmeal and beef -soup or beef -tea is always advisable when a 
nursling becomes anaemic without having been afflicted with a 
tangible disease. A small piece of beef, half an egg daily, a 
crust of bread, may be added about the end of the first year. 
The diet ought to remain simple, and mostly fluid or semi- 
solid until the child is two years old. Prevent bad habits, such 
as fast eating, and enforce regular defecation (not by medica- 
tion), plenty of exercise out of doors, and undisturbed and long 
sleep in a cool room. Avoid crowded school-rooms and pro- 
tracted lessons. "We have laws to protect children from being 
sent to work in factories, or to be employed on the stage, but 
none to protect them from the equally destructive, incessant 
schooling in close rooms, without air or exercise. There are 



DISEASES OF THE BLOOD AND CONSTITUTION. 127 

too many books bought for Christmas, and too few skates." 
(Arch, of Med., February, 1881.) 

The subject of nursing and artificial feeding, and of digestive 
organs, has been treated of elsewhere;* thus I abstain from dis- 
cussing the matter here beyond the above fragmentary remarks. 
What cannot, however, be emphasized too much or too often is 
the necessity of resorting to animal food — soups, teas, peptones 
— in cases of infantile ansemia. 

The medicinal treatment of anaemia must fulfil the causal 
indications first. That which depends upon chronic gastric 
catarrh requires, according to circumstances, alkalies or hydro- 
chloric acid, pepsin, bismuth. Besides the well-known subcar- 
bonate and subnitrate, the salicylate has made many friends of 
late. Pepsin and dilute hydrochloric acid are best when com- 
bined; a baby of a year may take six or eight drops of the latter 
in six or eight ounces of water daily, or the acid may be mixed 
with milk according to the formula given in a previous chapter. 
Disease of the kidneys has its own indications. The regulation 
of the heart's action — which, when abnormal, is the most fre- 
quent cause of habitual epistaxis, and of gastric catarrh and 
hepatic congestion — is the first indication in secondary anaemia. 
Many a gastric catarrh will not get well without digitalis or 
some other cardiac tonic, and persistent nose-bleeding is apt to 
improve immediately after the administration of digitalis, with 
or without iron. Thus, in a great many cases, anaemia is "cured 
by digitalis." In a similar manner digitalis can be utilized for 
the purpose of more competent oxygenization of the blood. 
When the heart is weak, and the lungs, by virtue of old pneu- 
monic infiltrations, offer too great a resistance to an easy circu- 
lation in the pulmonary vessels, it is again digitalis (or its 
equivalents) which facilitates the extensive contact of the oxy- 
gen of the atmosphere with a larger number of blood-cells. 



* A. Jacobi, "The Intestinal Diseases of Infancy and Childhood, 
Detroit, 1887. 



128 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

The insufficient innervation of the muscular tissue of the 
heart, stomach, and the rest, which is one of the most serious 
results of anaemia, is corrected very happily by strychnine or 
other preparations of nux. An infant a year old tolerates and 
requires one-fortieth of a grain of strychnine, or one-fifth of a 
minim of the fluid extract of nux, daily, for a long time in suc- 
cession. These preparations may easily be combined with any 
other medicinal administrations. 

Iron is looked upon as the sheet-anchor in anaemia. It is 
mostly indicated in cases of primary uncomplicated anaemia. 
A catarrhal stomach does not bear it well; when the stomach, 
however, is abnormal in consequence of the general anaemia, 
iron improves both the general condition and the stomach. 
In many of these cases the addition of bitter tonics is advisa- 
ble; strychnine is perhaps preferable. Anaemia after malaria, 
dropsy from anaemia and chronic nephritis, anaemia with neu- 
ralgia, anaemia with (and from) valvular diseases which do not 
result in local congestion, — mainly incompetency of the aortic 
valve, — are greatly benefited by iron. Anaemia after chronic 
diarrhoea requires great care in its use; in most cases it may, 
or ought to be, avoided. While it is very beneficial in the pre- 
disposition to hemorrhage, it should be avoided in haemoptysis. 
It is contraindicated in inflammatory fevers, for it increases 
pulse, arterial pressure, and temperature. But in infectious 
fevers, such as erysipelas and diphtheria, it is very efficient. It 
requires good digestive powers, which may be stimulated by 
aromatic tincture of rhubarb, tincture of cinchona, or by 
strychnine, and, to combat anaemia only, no large doses. The 
total amount of iron introduced into the system in the daily 
food does not exceed much a single decigramme (one and one- 
half grains), and that contained in the blood of the adult has a 
total weight of three grammes (two scruples) only. Still, it is 
quite possible that the iron introduced into the stomach fulfils 
more indications than that of supplying red blood-cells and (to 



DISEASES OF THE BLOOD AND CONSTITUTION. 129 

a lesser degree) haemoglobin. Indeed, it sometimes acts as a 
stomachic. 

Of the preparations mostly in use, either officinal or other- 
wise, I have mostly employed dialyzed iron, a few minims 
several times daily, the tincture of the malate (pomate), twelve 
to thirty minims daily, and the same, or somewhat smaller 
doses, of the tincture of the chloride of iron. The dry prepara- 
tions are the phosphate, one-half to two grains three times a 
day, and the same doses of the carbonate (saccharated). The 
latter is aptly combined with proper doses of bismuth. The 
p)Tophosphate demands smaller doses. The lactate is a mild 
and digestible preparation which seems not to be appreciated 
at its full value. The citrate of iron and strychnine, and that 
of iron and quinine are valuable preparations when the effects 
of the combinations are sought for. Coming with the recom- 
mendations of Schmiedeberg, ferratin in several daily doses of 
one or two decigrammes (grs. 1J-3) each, has been awarded a 
fair trial; so have some other preparations, the peptonate, the 
albuminate, the peptomanganate. The obtrusive methods of 
advertising them do not prove their superiority over the drugs 
and preparations of the Pharmacopoeia and of the National 
Formulary. The syrup of the iodide of iron is well tolerated 
by the youngest infants; as many drops as the baby has months 
may be given three times a day up to eight or ten drops a dose. 
It is well tolerated by the stomach, in which the iodine is freed 
from the iron and acts as an antifermentative. Besides, ex- 
perience appears to confirm the theoretical inference that it 
proves its power as an absorbent in cases of anaemia complicated 
with glandular enlargements. The syrup of the hypophos- 
phites cum ferro of the Pharmacopoeia may be given in larger 
doses; this is the preparation which I frequently select when I 
mean to add the fluid extract of nux vomica. It is self-under- 
stood that I prefer the legitimate preparations of the Pharma- 
copoeia to the wares of the agents and advertisers, "physicians' 
samples" or no. 

9 



130 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Other (animal, like ferratin) preparations of iron are Ro- 
bert's haemol and hsemogallol. It has been suggested, not 
proved, that their animal origin renders them more homo- 
geneous. 

For subcutaneous administration the pyrophosphate of iron 
with citrate of sodium, also the albuminated iron have been 
recommended; also, by Rummo, a ten-per-cent. watery solution 
of the ammoniated citrate of iron, and by Lepine, one of a 
two-and-a-half-per-cent. solution. As anaemia is a chronic con- 
dition which requires "chronic" treatment, and the injections 
cause pain, it is not very probable that this mode of employing 
the remedy is very available. 

The administration of iron appears to have an indirect effect 
also, which is apt to do much good. As a rule, the inhalation 
of oxygen gas, continued for five or ten minutes, at intervals 
of from an hour to two hours, seems to improve sanguinifica- 
tion and metamorphosis considerably. This wholesome action, 
it always seemed to me, was most perceptible while iron was 
administered. To admit oxygen red blood-corpuscles are re- 
quired; it appears that the influence of iron on their organiza- 
tion and numbers renders the introduction of oxygen into the 
blood easier and more beneficial. Oxygen was often credited 
with being a general tonic, and its inhalation was considered 
at one time almost a panacea. As long as the organs of respira- 
tion and circulation are normal, the atmospheric air contains 
more than they require. Still, whenever they are disordered, 
in the orthopncea of pneumonia, in asthma and emphysema, 
in pulmonary tuberculosis, in cardiac diseases (as also in poi- 
soning with carbon oxide, or when there is methaemoglobin in 
the circulation), and in anaemia depending on these condi- 
tions, the inhalation of oxygen is of undoubted service. It has 
the advantage of being readily prepared pure; that is more 
than we can say of ozone. (See p. 81.) 

Some of the worst forms of anaemia are greatly benefited by 
arsenic. They are those which result from long-continued in- 



DISEASES OF THE BLOOD AND CONSTITUTION. 131 

anition and slow convalescence, in which the stomach does not 
suffer primarily; from primary catarrh; from chronic malaria; 
from chronic tuberculosis of the lungs; from chronic glandular 
swellings of a malignant type, either lymphoma or sarcoma or 
adenoma. In all of these forms it is highly useful. The doses 
need not be large, but may be increased slowly. One one-hun- 
dredth of a grain of arsenous acid, or one drop, or one and a 
half, of Fowler's solution, three times a day, after meals, the 
latter amply diluted, are well borne for weeks, even months, 
without interruption, by a child of four or five years. In 
malaria, the remedy may be given with quinine (and iron), in 
other forms with strychnine (and iron); in pulmonary tubercu- 
losis, with digitalis. 

The gradual increase of the doses of arsenic may be effected 
in the following manner: A drachm of Fowler's solution is 
diluted with sixty drachms of water; three doses of this mix- 
ture are given daily. If the initial dose is to be one drop, give 
a teaspoonful; the next dose is a teaspoonful + one drop, the 
third dose a teaspoonful + two drops, and so on, until the 
sixty-first dose consists of a teaspoonful and sixty drops. Thus 
the original dose is gently and slowly doubled in twenty days. 

Children bear arsenic better than adults, and very much 
better than senile patients. Still, even they must not take it 
when they are affected with gastric disorders; nor continue it 
when in the course of treatment conjunctivitis, oedema of the 
eyelids and face, or diarrhoea make their appearance. 

Among the sjTnptoms, or consequences, of anaemia there 
are two of great prominence; first, insufficient tissue-forma- 
tion, and, second, incompetent innervation. To what extent 
spermin, which is not only claimed as a constituent of sperma, 
but of most or all tissues, deserves its exorbitant praise as a 
tonic remains to be seen. It is said to stimulate oxidation in the 
organic cells and to produce leucocytosis. The dose is, for an 
adult, a cubic centimetre of a two-per-cent. solution. 

This dietetic and medicinal treatment, mostly so effective in 



132 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

simple anaemias, is also indicated in chlorosis when it develops 
in children. In them the anatomical cause giving rise to life- 
long chlorosis — viz., persistence of the foetal smallness of the 
aorta (Yirchow) with smallness of the general arterial system — 
cannot be wholly overcome. It is here that bitter tonics 
should be added from time to time to the preparations of iron 
and digitalis to stimulate arterial and cardiac action. Both of 
these require the continued use of cold water, — viz., daily wash- 
ing or bathing with vigorous rubbing, and systematic exercise. 
The diminution of haemoglobin, while the number of red blood- 
cells is more or less normal, requires ample and cautious feed- 
ing; it is here that peptones to such an extent as can be ab- 
sorbed are indicated. It should never be forgotten, however, 
that all the symptoms of chlorosis in a child (as in the grown 
woman) may be caused by undiscovered malignant tumors or 
by gastric ulcerations (not so very uncommon). 

Pernicious (essential) ancemia is characterized by a decrease 
of red blood-cells (from four or five millions in a cubic centi- 
metre to one or even one-half of a million), which, moreover, 
exhibit irregular sizes and shapes (poikilo-, micro-, and megalo- 
cytes), while haemoglobin is not reduced at the same rate. 
When it is caused by atrophy of the peptic glands (Kinnicutt), 
or prolonged icterus, or syphilis, or entozoa (ascaris, taenia, 
bothriocephalus), the indications are clear. Many such cases 
get well when treated for known causes. That is why every 
addition to etiology is so welcome. Ewald has found atrophy 
of the small intestines in many cases of pernicious anaemia. 
Knud Faber published a case (Berl. Tclin. Woch., July 26, 1897) 
which seems to prove its connection with a stricture of the 
small intestine. If a diagnosis could have been made in his 
case it is possible that an operation would have prevented 
anaemia. As other such strictures (tubercular, syphilitic), 
quoted by him, are also known to have been connected with 
intense anaemia, the suspicion is justified that an intestinal 
toxin caused or occasioned by them (as also by apepsy and hel- 



DISEASES OF THE BLOOD AND CONSTITUTION. 133 

minthes) is the source of the rapid destruction of blood-cells 
and the cause of pernicious anaemia. If that be so, intestinal 
antisepsis, if it ever will be accomplished to a sufficient degree, 
will cure many a case. Of the remedies mentioned above, 
arsenic in rising doses is quite effective; iron and small doses 
of quinine act as adjuvants; bone-marrow (when raw or boiled, 
it nauseates quickly) or its preparations (Armour's, "carno- 
gen"), the daily doses of which may vary from one-half of one 
to two teaspoonfuls, has been credited with good effect. I have 
seen improvement, but no cure. Weir Mitchell's rest and feed- 
ing cure, with general massage, benefited some. The capricious 
appetite prefers mostly a vegetable diet, the failing digestion 
requires stimulants (strychnine), besides pepsin with hydro- 
chloric acid; the absence of blood-cells and the consequent 
inability to bind oxygen and to produce heat demand warm 
clothing and warm rooms; diarrhoea, its symptomatic treat- 
ment; and utter debility and collapse, infusion of salt water. 

The prognosis of leucocythcemia (leukcemia) is still worse than 
that of pernicious anaemia. From the latter it is diagnosticated 
by the increase of leucocytes (1 : 50-2, instead of 1 : 250-350) 
and the increase of eosinophile cells. It is known to follow, in 
instances, malaria, influenza, syphilis, glandular, and bone-dis- 
eases; and prevention is therefore a possibility. Albuminoids 
in blood and tissues are rapidly destroyed; therefore albu- 
minoids in every possible shape, peptones, albumoses, etc., 
should be given in absorbable quantities. Rest, massage, cold 
and heat, transfusions, infusions, oxygen inhalations, arsenic 
and iron, quinine, bone-marrow, injections of ergotin into the 
subcutaneous tissue, of arsenic into the spleen, electricity and 
galvanism, extirpation of the spleen (all fatal), treatment of 
the accompanying hemorrhage, of perspiration, of pleuritis, 
and of ascites, — all are in vain. I know of no authentic case, 
either acute or chronic, that recovered. 

Pseudoleukemia (Hodgkin's disease), though there are so 
many transformations of this form of anaemia into leucocy- 



134 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

thaemia as to make a common origin (infection ?) and nature 
very probable, has in most cases its own symptomatology 
(swelled lymph bodies all over the body, swelled liver and 
spleen, no leukaemic blood, merely leucocytosis). The diagnosis 
from general sarcomatosis, which causes inflammatory adhe- 
sions between the lymph bodies (isolated in pseudoleukemia), 
is not always easy. Arsenic is again the sheet anchor. Piperin, 
five to fifty centigrammes or more daily (grs. 1-10), has been 
recommended. Berberin sulphate seems to deserve credit; it 
certainly stops the troublesome constipation, but should not be 
given in such doses as to cause diarrhoea. It seems to improve 
the appetite and to reduce the size of the glands and of the 
large viscera. 

Splenic ancemia, with its large spleen and somewhat swelled 
liver, no leucocytosis, but poikilocytosis, and some diminution 
of haemoglobin, and some nucleated blood-cells, does not de- 
serve a place of its own in our nomenclature. It shares the 
therapeutical indications of its sister anemias. 

2. Rhachitis. 

Many cases of rhachitis which depend on hereditary influ- 
ences might have been prevented or modified by attending to 
the parents before conception, or to the mother during preg- 
nancy. I have known women to bear healthy or rhachitical 
children according to the condition of health or ill health dur- 
ing the year preceding parturition. A number of their constitu- 
tional ailments, such as anaemia, tuberculosis, and syphilis, 
make their appearance in the offspring with the symptoms of 
rhachitis. If that precaution have been neglected, the injury 
inflicted upon the infant cannot be completely annulled; in 
many cases, however, it can be greatly moderated. Thus there 
are a great many cases of early rhachitis which are due to the 
influence of mitigated syphilis in the parents. Indeed, some of 
the microscopical bone-lesions of the two diseases, as they are 
met with in the newly-born, are difficult, some impossible, to 



DISEASES OF THE BLOOD AND CONSTITUTION. 135 

distinguish from each other. Such cases can be greatly bene- 
fited by an antisyphilitic (mercurial) treatment, which should 
be continued through a period of many months. 

Attention should be paid to general hygiene. More can be 
accomplished by furnishing good air than by any other means. 
The air of the winter is no contraindication to keeping win- 
dows open and to taking the young baby out as long as there is 
ample clothing and covering. Sea-air is preferable as long as 
there is no contraindication, for instance, in the condition of 
the respiratory organs. 

Sojourning in the country is beneficial only when the 
rhachitical infant is not locked up in the house. Sea-air, to- 
gether with sea-bathing, warm, cool, or cold, according to 
age, condition, and training, is an excellent preventive and 
curative measure. England commenced that practice on a 
large scale in 1750; Italy, France, Germany, America, these 
last twenty years only. The sea-hospitals have done an im- 
mense amount of good. To eradicate rhachitis, however, the 
children must be kept on the shore for years. In America we 
are always too much in a hurry and expect the benefits of 
heaven and earth in a particle of a season. When no sea-shore 
is accessible the bathing in salt water with friction, massage, 
occasionally with electricity, may be done at home. When 
eczema is caused by it, the salt-water treatment should be dis- 
continued. 

Plenty of air by day and by night, coupled with poor food, 
is still safer than the best possible food with bad air. Comby's 
saying that rhachitis gets access through the stomach, not 
through the skin or lungs, requires a good deal of modification. 
Still, the nature of the food is highly important. Lactation 
must not be continued be3^ond the appearance of two or four 
teeth. A wet-nurse should not be too young nor too old. But, 
after all, even an apparently proper age or condition of mother 
or wet-nurse does not always exclude the possibility of a breast- 
fed baby becoming rhachitic. In such a case a well-selected 



136 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

artificial food is preferable to breast-milk. Pure cow's milk, 
when given as exclusive food, no matter whether raw or boiled, 
is harmful. Artificial foods must be well selected and watched. 
The absence of pathogenic germs from them is not the only 
safe-guard. Even Botch's modified milk and Gaertner's fat milk 
do not protect against rhachitis, though they be fairly proof 
against microbes. The addition at an early date of cereal de- 
coctions, barley, oatmeal, and of animal broths, renders all 
the known milk preparations safer and more wholesome. Too 
large a percentage of fat in the foods of young infants should 
be avoided. The addition of fat is not always a protection 
against rhachitis, and may easily be overdone. Diarrhoea, dys- 
pepsia, from whatever cause, and constipation should be cor- 
rected, and the warning often expressed by me and urged by 
Comby should not be forgotten, that over-alimentation is at 
least as dangerous as under-alimentation. That the skin re- 
quires intelligent attention was suggested above. Whether a 
bath should be given immediately after birth and continued 
regularly during the first weeks ought to depend on the nature 
of the individual case. As a general rule, which is valid for 
every child, bathing — first tepid, later on cooler, in salt-water 
when there appears to be an indication for more surface stimu- 
lation, with appropriate friction — improves both the cutaneous 
and the general circulation. 

Ehachitis due to, or connected with, digestive disorders de- 
mands the correction of the latter. Gastric catarrh is not fre- 
quently primary; more commonly it is the consequence of 
faulty diet; but in both cases it is the cause of anagmia, and 
either of insufficient or of abnormal secretion of both the mu- 
cous membranes and the glands. The gastric catarrh of 
rhachitis is pre-eminently acid, thus neutralization of the 
stomach is often required before every meal and between 
meals. Prepared chalk, calcined magnesia, bicarbonate of 
sodium, the several preparations of bismuth, find their proper 
indications in this condition. The salicylate of bismuth, ani- 



DISEASES OF THE BLOOD AND CONSTITUTION. 137 

mal carbon, resorcin find their places, besides aromatic teas, in 
complications with fermentative processes in the intestine and 
with excessive flatulency. When the secretions of the stomach 
are merely insufficient, the addition of chloride of sodium in 
proper quantities will facilitate the formation of hydrochloric 
acid. When that plan does not suffice, pepsin and muriatic acid, 
the latter largely diluted, will take the place of the physiological 
gastric juice; and bitter tonics and alcoholic stimulants, also di- 
luted, will stimulate a normal secretion. Still, the selection of 
a proper food forms the main part of the indications. The 
principles of infant feeding, both in health and disease, I have 
laid down in the first part of this book; to that I refer; also to 
my suggestions, in the same place, on the selection of animal 
foods so urgently required in rhachitis. 

Cod-liver oil, when tolerated, influences rhachitis favorably. 
As a rule, however, it is not so universally well borne in 
rhachitis as it is in "scrofula." I do not advise the use of its 
compounds, emulsions, and so on, except when it is disliked or 
the latter have some other indications, for instance, diarrhoea; 
this is sometimes produced by the oil, mainly in the hot season. 
In that case the remedy may have to be discontinued, or may 
require the temporary addition of bismuth or phosphate of 
calcium. The action of cod-liver oil is considered by some hy- 
gienic only, by others remedial. The former attribute its 
effects to the fat, and believe the substitution of any assimilable 
fat an equivalent. As I said before, I do not believe its agency 
to be thus restricted, for three teaspoonfuls of cod-liver oil will 
never be replaced by three teaspoonfuls of cream or other fat. 
Universal experience teaches its wholesome influence in many 
morbid tissue-changes. Possibly the mystery of its action is 
best explained by attributing to it a percentage, though ever 
so slight, of some organic tissue juice of a nature and efficacy 
to be compared with that of the thyreoid gland. Tempted by 
that point of view, Heubner tried the action of thyreoid gland 
in rhachitis, but without any tangible effect. He believes, 



138 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

however, that the general condition of the infants appeared 
to be improved by it. 

Malt and "maltine" preparations have found favor both 
with the profession and the public. Unfortunately the 
market has been swamped with all sorts of combinations and 
mixtures to such an extent as to shake confidence in their 
honest composition in the same degree as the mere object of 
making money by it becomes pre-eminently clear. 

Though rhachitis be a general disease, and not merely one 
of the osseous system, the anomalies exhibited by the hones 
are apt to attract most attention. The changes exhibited in 
the shape of the chest, which result from the pressure of the 
atmosphere on the soft rhachitical ribs, are not liable to disap- 
pear entirely. The "pigeon-breast" — that is, the prominence 
of the sternum and (or) the costo-cartilaginous junctures — re- 
mains for life to a greater or smaller degree, according to the 
severity of the affection or to the restoring power of the ex- 
panding lungs. It requires early medical and surgical inter- 
ference and protracted gymnastic exercise. Even crying is 
welcome, and in children of two or three years trumpet-blow- 
ing, soap-bubbling, etc. The curvatures of the diaphyses of the 
long bones are apt to be less marked in the adult because of the 
extension which takes place during growth. If ever splints 
are to do any good they should be applied before the bones 
have become hard again; the eburnation following the softness 
of the bones after recovery resists every degree of permissible 
pressure. The tendency to flat-foot, acquired through the flab- 
biness of the ligamentous apparatus during the attempts of the 
child at locomotion, requires massage and sustaining by a shoe 
made strong enough to support the ankle and a steel spring 
just sufficiently strong to restore the arch of the foot; scoliosis, 
a Sayre's plaster-of-Paris or a felt jacket; the rhachitical 
groove round and above the insertion of the diaphragm, well- 
directed gymnastics of the chest; inflexible and ugly curva- 
tures of the long bones, either osteoclasy (fracturing of the 



DISEASES OF THE BLOOD AND CONSTITUTION. 139 

curved bone while leaving the periosteum intact, and resetting) 
or- osteotomy (straightening the bone after it has undergone a 
cutting operation). Of these two, osteoclasy was the only oper- 
ation resorted to formerly. The fracture of the bones was 
either manual or instrumental, mostly successful in the middle 
of the femur or tibia, mostly unsuccessful for genu valgum or 
varum inasmuch as it often tore off the epiphysis or fractured 
in an undesirable place, and was sometimes followed by septi- 
caemia. 

Osteoclasy has been mostly replaced by osteotomy. It is a 
simple and open operation. It is seldom required on the upper 
extremity, mostly on the lower, not so often on the thigh as for 
genu valgum and varum, or for the curvatures of diaphyses. 
The genu valgum of children results from the curvature both of 
the femur — usually the only one at fault in adolescents — and of 
the tibia. It requires the supracondyloid operation of Mac- 
ewen, and often a supplementary operation on the tibia. The 
curvature of the tibia has mostly its concavity interiorly and 
posteriorly, and is usually found at its lower half. The opera- 
tion may be either simply linear, transverse or oblique, or 
cuneiform (wedge-shaped). In bad cases the latter is preferred, 
and not seldom a single operation is insufficient. An interval 
of a few weeks is ample between the several operations that 
may become necessary. The results of osteotomy are almost 
alwa} T s absolutely good. Suppurations there are a few only, and 
controllable. 

During the acute rhachitical process the bones will not only 
bend, but are liable to be changed in their continuity. It is 
true that genuine fractures are not quite frequent because of 
the very softness of the bones and the succulence of the peri- 
osteum. But infractions (green-stick fractures) are quite com- 
mon about the extremities and clavicles. The periosteum never 
participates in the injury; the bone is more or less bent upon 
itself; the ends are not entirely separated and are easily re- 
adjusted, but require splinting until the rhachitical process 



140 THERAPEUTICS OE INFANCY AND CHILDHOOD. 

has terminated in general recovery. Immobilization of the 
entire body is sometimes required when the tendency to infrac- 
tion is quite extensive. 

Many of the serious results of softness of the bones could 
be avoided or mitigated by precautionary measures. Babies 
in general, and those with incipient rhachitis in particular, 
must not be made to sit up before their vertebral columns and 
their dorsal muscles are able to support them. They must not 
be carried about in an erect posture, nor on the same arm 
always; that practice is an invariable cause of scoliosis, and 
frequently of genu valgum of one side, and of genu varum of 
the other. They must be kept and carried about in a reclining 
posture; better on a hair pillow than on the arm until they 
feel strong enough to do without it. Thus scoliosis can be pre- 
vented. They must be discouraged to walk before their limbs 
are sufficiently strengthened; no walking baskets should be em- 
ployed, no fond and proud grandparents allowed about; thus 
the curvatures of the diaphyses of the lower extremities, which 
in part result from the vertical weight of the body on the feeble 
limbs and the secondary deformities of the pelvis, are reduced 
to a minimum. 

Craniotabes, the rhachitical softening of the cranial bones, 
is one of the earliest symptoms of the disease. The bones 
which commenced their postnatal ossification in a normal man- 
ner begin to soften to such an extent that the parietal and 
occipital bones exhibit a number of spots in which the osseous 
tissue has nearly entirely disappeared. The hair falls out in 
that neighborhood, the scalp is perspiring copiously, the veins 
get dilated, the bones and meninges become hypera3mic, and 
meningeal effusions are quite frequent. The softness of the 
bones results in asymmetry of the cranium, which is flattened 
by the very pressure of a soft pillow. This asymmetry is liable 
to disappear after recovery, except in grave cases. 

The local hyperemia and excessive occipital heat forbid the 
use of warm bonnets and feather pillows. A soft hair pillow 



DISEASES OF THE BLOOD AND CONSTITUTION. lil 

must be so arranged that the head, together with the body, can 
be comfortably carried without any pressure. Elsaesser (1843) 
recommended a pillow with a central depression or perforation; 
a small air-cushion filled to one-third of its capacity is very 
acceptable. Consecutive brain symptoms require appropriate 
treatment. Great convulsibility demands bromides, chloral, 
and mild opiates, which are well tolerated in this condition. 
The perspiration requires cooling with water, or water and 
vinegar, or powdering with one part of salicylic acid mixed 
with ten parts of oxide of zinc and twenty-five of starch. The 
general treatment of rhachitis improves this local cranial symp- 
tom, which is quite serious. In former years I was in the habit 
of giving a good prognosis provided the next six or eight weeks 
would pass without fatal symptoms (convulsions, etc.). That 
period was generally sufficient to so change both the general 
nutrition and the local condition as to restore a fair average of 
health both in the cranium and its contents. The experience of 
late years has shortened this period. What I suggested in a 
brief paper on the use of phosphorus in the treatment of 
chronic and subacute diseases of the bones in the "Transactions 
of the Medical Society of the State of New York," of 1880, and 
in a paper on ansemia in infancy and childhood read before 
the Medical Society of the County of New York in 1880 (Arch, 
of Med., February, 1881), has proved a great success in other 
hands. For it is to Kassowitz that the credit of the introduc- 
tion of phosphorus as the principal remedy in rhachitis is 
mainly due. When, twenty years ago, C. Wegner fractured the 
bones of rabbits and fed the animals on minute doses of phos- 
phorus, he found that these bones would heal in a much shorter 
time than those which were not so supplied. This observation 
induced me to employ the drug in all cases of (mostly tubercu- 
lous) subacute and chronic ostitis, Pott's disease, and caries of 
the tarsus; and a great many cases led me to conclude that re- 
covery was more readily accomplished under this treatment. 
Phosphorus is, by virtue of its irritating effect, when given in 



142 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

small doses, a tissue-builder (Kassowitz claims that it impedes 
the formation of blood-vessels), when in large doses, a tissue- 
destroyer. In the former it would in part act through the rapid 
development of connective tissue, similarly to what Lanne- 
longue expects to attain by the local injections of chloride of 
zinc solutions. Thus I became convinced of its tissue-building 
properties in other parts also. I may mention here, before I 
shall have an opportunity to return to the subject in extenso, 
that I have availed myself of this quality of phosphorus for 
other purposes also. It has served me well in many ominous 
cases of purpura and similar processes, in which a congenital 
or acquired ill nutrition of the blood-vessel walls results in 
habitual hemorrhages. 

Kassowitz's results with the use of phosphorus in rhachitis 
are generally good. The cases in which it has rendered me 
its best services are exactly those alluded to, of craniotabes. A 
very few weeks suffice to change the condition of the cranial 
bones considerably, the softened parts become smaller and 
harder, and the consecutive symptoms milder. It is of equal 
value in acute rhachitis, with its extensive acute epiphysitis, 
rapid pulse, diarrhoea, general feebleness, and (frequently) 
symptoms of scurvy. 

The dose of phosphorus in these cases is from one-third to 
one-half of a milligramme three times or twice a day. The 
oleum phosphoratum of the U. S. Pharmacopoeia contains one 
part of phosphorus in ten parts of ether and ninety of oil. Its 
daily dose is from two to three minims. Concentrated oil solu- 
tions are liable to get decomposed. "Thomson's solution" keeps 
fairly well, but the best preparation is the elixir of phosphorus 
of the TJ. S. Pharmacopoeia, composed of 210 parts of the 
spirit of phosphorus, 2 parts of oil of anise, 550 parts of glyc- 
erin, and a sufficient quantity of aromatic elixir to make 1000 
parts. Of this elixir a teaspoonful contains one milligramme of 
phosphorus, and a dose, to be repeated three times a day, is 
from six to fifteen minims. No temptation ought to be strong 



DISEASES OF THE BLOOD AND CONSTITUTION. 143 

enough to employ phosphates, which will invariably reappear 
both in the urine and in the faeces. It seems probable, more- 
over, that the phosphates contained in nutriment are more 
digestible and more assimilable. Phosphates are much inferior 
in effect to the hypophosphites of the Pharmacopoeia with or 
without iron. Phosphorus given simultaneously with cod-liver 
oil is a good combination, but it is a doubtful practice as long 
as the latter is not a uniform compound to dissolve phosphorus 
in the oil. Where anaemia is intense, the preparations of iron 
are required. Besides the above, the syrup of the iodide of 
iron may be given, as many drops three times a day as the baby 
is months old, or from ten to twenty-five drops three times 
a day to children of from one to two or three years. "When 
the spleen and also the lymph-bodies are very large, three 
daily doses of one-half to one drop of Fowler's solution is bene- 
ficial. In scorbutic cases or complications, fruit-juices are re- 
quired. Heubner's experience with phosphorus in bad hospital 
cases is negative. The famous teacher knows, however, that 
bad rhachitis never does well in hospitals. If it requires any- 
thing, it is air, air, and again air! To his discomfiture, how- 
ever, we owe some observations which, though they be negative, 
are valuable. Guided by what he takes to be a fact, that all 
irritations and inflammations from known causes are local, 
and by Lanz, who finds certain relations between the thyreoid 
and bone development, and suggests a trial of thyreoid in 
rhachitis, he gave from one-half to one decigramme of Merck's 
thyreoidin every other day, or every day, with negative result as 
far as improvement of rhachitis was concerned; with a favora- 
ble effect, however, he believed, on the general condition of the 
child. 

Laryngismus stridulus, the crowing inspiration of infants, is 
almost always connected with craniotabes, and caused by its 
meningeal and encephalic results. It consists of two stages, 
the first of which is that of paralytic apncea, the second of a 
long-drawn and loud inspiration through the spastically con- 



144 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tracted glottis. The causal treatment is that of rhachitis in 
general, of cranial rhachitis in particular. Before, however, it 
can accomplish a permanent effect the single attacks of, and 
the general tendency to, laryngismus require attention. For 
any attack may prove fatal, though the assertion of Vogel, 
who expresses the opinion that most cases of laryngismus are 
fatal, is grossly exaggerated in my opinion, which has not 
changed in this respect since my utterances in 1871.* Besides 
phosphorus, syrup of the iodide of iron, and other treatment, 
constipation requires more than the usual attention, for the 
nerve-equilibrium is easily disturbed by a slight irregularity 
in any of the organic functions. To soothe its general vul- 
nerability the regular administration of the bromides (twelve 
or fifteen grains daily of a mixture of the potassium, sodium, 
and ammonium salts) or a few grains daily of the valerianate 
of zinc are indicated. Many cases bear one-sixth of a 
grain of codeine in the twenty-four hours. These cases of ex- 
cessive irritability are quite precarious. In them the ears re- 
quire particular attention, for the slightest (external or) in- 
ternal otitis is liable to produce convulsions. In them even 
the lancing of gums, where there is but a suspicion of local 
pruritus, may become pardonable. The attack can be cut short 
by shaking the infant, or slapping the face with a cloth dipped 
in water, or using the spark of a Leyden flask (for there is no 
time for the administration of the interrupted current). Gen- 
eral convulsions, which are not uncommon at all after an at- 
tack, require the inhalation of chloroform or the rectal injec- 
tion of from four to eight grains of chloral hydrate. 

The rhachitical disorders of the respiratory organs owe their 
origin to several causes. In rhachitis the heart is of average 
size, but the arteries are abnormally large. Great width of 
arteries lowers the blood-pressure. That is why the muscles 
and bones suffer from insufficient nutrition; and why the circu- 

* American Journal of Obstetrics. 



DISEASES OF THE BLOOD AND CONSTITUTION. 145 

lation in the respiratory organs is slow and sluggish, with a ten- 
dency to produce congestion and catarrh. Other causes of the 
chronic bronchial catarrh of the rhachitic infant, which is so 
apt to become bronchitis and terminate in broncho-pneumonia, 
depend upon the smallness, particularly of the lower half, of 
the contracted chest, which compresses the lungs; and the 
tumefaction of tracheal, bronchial, and mediastinal gla?ids, 
which are in close lymph communication with the bronchial 
mucous membranes. There are but few thoroughly developed 
cases of rhachitis, when complicated with bronchitis, without 
them. Not infrequently can some of them be felt in the supra- 
clavicular spaces; more commonly can they be percussed behind 
the manubrium sterni, the dulness of which is in many cases 
but partly thymic. Sometimes they can be discovered by per- 
cussion of the infraclavicular region of the (right or more fre- 
quently the) left side and often on the left side of the intra- 
scapular region. These glandular swellings, which point to 
and explain the frequent relations of rhachitis, scrofula, and 
tuberculosis with each other, are no uncommon appearances in 
the autopsies of rhachitical babies who finally died of the last 
developments of their chronic catarrh. 

This tendency to glandular swellings requires early attend- 
ance. It is here where cod-liver oil and the syrup of the 
iodide of iron are mainly serviceable. In many cases the addi- 
tion of half a minim of Fowler's solution, administered three 
times a day, acts favorably. This is the condition of things in 
which the use of cold sponging, salt-water bathing, salt air, are 
particularly beneficial. Out-door life must be insisted upon, 
and there are but few reasons — mostly of a local character — 
which forbid such babies to enjoy fresh air at all hours of the 
day and night. 

Subacute or acute inflammations of the respiratory organs, 
when they have made their appearance during the chronic 
rhachitic catarrh, require, besides the usual rational treat- 
ment, some additional measures. More care, than in an average 

10 



146 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

case of the otherwise healthy, must be taken lest the faltering 
strength be exhausted before the acute disease has had time to 
run its course. The sluggish circulation, depending on general 
debility and the large size of the arteries, demands the ad- 
ministration of heart tonics, — digitalis, strophanthus, spar- 
teine, caffeine, or coffee, from the very beginning, and besides 
small doses of alcoholic stimulants at an early stage, or the use 
of stimulant expectorants, such as carbonate of ammonium or 
camphor. There is a positive contraindication to antimonials 
and squills; even ipecac must be avoided because of its possibly 
depressing effect. 

Rhachitic constipation is mostly due to the incompetency of 
the muscular layers of the intestine and of the abdominal wall. 
Thus purgatives must be avoided in its treatment, with the ex- 
ception of those cases in which the accumulation of faeces in 
the bowels happens to be attended with serious consequences. 
In these an occasional dose of calomel will act both as a lax- 
ative and a disinfectant. When an acid gastric catarrh accom- 
panies the intestinal weakness, calcined magnesia in doses of a 
grain, given on an empty stomach, or before meals (never 
after), repeated several times daily, will neutralize the ab- 
normal acidity of the stomach while opening the bowels. A 
daily enema of tepid water continued for years will mostly 
suffice to alleviate the troublesome symptom. Cod-liver oil, 
while being administered on account of the general indications, 
has also a beneficial local effect. Pure cow's milk is more con- 
traindicated in this condition than in almost any other. Arti- 
ficial food should contain a copious addition of salt and sugar, 
and oatmeal rather than barley. Gentle massage of the ab- 
domen, and strychnine, one two-hundredth of a grain, three 
times a day, improves the muscular strength. The syrup of 
the iodide of iron, in three daily doses of a few drops, and the 
regular administration of beef preparations," will improve con- 
stipation with the other symptoms; particularly when this 
treatment is commenced at an early period. For it is at an 



DISEASES OF THE BLOOD AND CONSTITUTION. 147 

early period, generally in the second or third month, that 
this rhachitic constipation will make its first appearance. 
It is one of the first symptoms of protracted rhachitis, 
and is diagnosticated from what I have described as congenital 
constipation — which depends on an abnormal length of the sig- 
moid flexure — by the fact that the latter begins at birth. 

3. Scrofuhsis, — Scrofula. 

The discrimination between scrofula and tuberculosis is at- 
tended with no difficulty for those who claim the bacillus of 
Koch as the pathognomonic essence of the latter. For all 
others, and so it was before the period of the bacillus, the dis- 
tinction may not be quite so easy; at all events, the boundary- 
lines between scrofula and tuberculosis are not always quite 
marked. But it is certain that the bacillus need not be present 
in the former as long as it remains uncomplicated. 

We speak of scrofula in persons who exhibit a great ten- 
dency, with no apparent, or upon the slightest, provocation, to 
subacute or chronic inflammation of most tissues, mainly the 
cutis and mucous membranes, sensory organs, glands, bones, 
and joints. These inflammations are persistent and liable to 
return; they run their course both with rapid formation and 
disintegration of the cells, equally in the erethic and torpid 
forms. Of these, the former is recognized by a frail and thin 
stature, delicate features, great intellect, blue sclerotic, and 
large pupils; the latter, by coarse and expressionless face, 
cedematous lips and nose, congested eyes, large abdomen, 
swollen glands, and frequent cutaneous eruptions. 

It is the commendation of modern therapeutics to be mostly 
preventive. So is the treatment of scrofula. Many cases of 
the disorder would not appear if our modes of thinking and 
feeling, our habits and laws, were not the immediate results of 
individual egotism. As long as the welfare of the common- 
wealth, both present and future, does not supersede, in the 
convictions of the many, the dictates of selfishness, there will 



148 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

be no restriction on the marriages of the scrofulous, syphilitic, 
and tuberculous, and the propagation and proliferation of their 
dangerous ailments. If the mankind of the future means to be 
healthy and happy, there must be found some mode of prevent- 
ing hereditary influences from having full sway. We are no 
Spartans, who kill the unhealthy newly-born, but we are to 
develop into men who pity those laden by their very parents 
with the eternal curse of illness, and citizens who feel respon- 
sible for the physical and intellectual welfare of the com- 
munity. In the United States, scrofula has been on the in- 
crease at a rapid pace since the immigration of the most abject 
parts of the most abject peoples of the Old World has been 
allowed to swell our numbers by the hundreds of thousands for 
each of the last dozen years. 

An important preventive measure is the suppression of the 
attacks of acute diseases in children, mainly the eruptive fevers. 
Upon a former occasion I have emphasized the necessity of 
medical (hygienic and pharmaceutical) treatment of most cases 
of sickness. It is particularly measles and scarlatina which are 
liable to interfere with the subsequent normal development, — 
the former through its influence on the respiratory, the latter 
through its effect on the digestive and lymphatic systems, and 
also on the bones. The modification of a severe form into a 
milder form, and the early restitution of the physical functions 
to a normal standard, is a gain for life. 

Scrofula being frequently the direct result of digestive dis- 
orders, resulting either from improper food or nutriment im- 
properly given or insufficiently digested, the greatest care is 
to be bestowed on both food and the digestive organs. This is 
of more than the average importance in regard to the offspring 
of tuberculous parents. No tuberculous mother must nurse her 
own infant. The selection of the wet-nurse must be the most 
painstaking, and the period and mode of weaning must be 
supervised with the utmost care. Afterwards amylaceous food, 
particularly potatoes, should be avoided, or given in small quan- 



DISEASES OF THE BLOOD AND CONSTITUTION. 149 

tities only. Good milk (boiled), cereals, and meat, with the ad- 
dition of fruit, ought to be the principal food of children up to 
their tenth or twelfth year. Stimulants must not be given 
except on proper and exceptional indications; thus tea, coffee, 
alcohol, beverages of any kind, are forbidden articles of diet. 
Cocoa must take the place of chocolate. The best beverage is 
water. It supplies every want, and when taken in sufficient 
quantities is the best stimulant of tissue metamorphosis. In 
the very rare cases in which a sensitive stomach does not bear 
it well a carbonated or (and) slightly alkaline water will take 
its place. 

Among the foods, cod-liver oil ranks high. Most children 
take it readily after a short time, and are anxious to have it. 
Thus there was no necessity of peptonizing, emulsionizing, or 
"hydroleinizing" from the point of view of the children, or of 
practice. Of the reprehensibility of filling the child's diges- 
tive organs with unlimited lime I have spoken in another place. 
The oil can be taken through successive 3 r ears. Its adminis- 
tration ought to be interrupted during warm days and during 
the summer. Still, there are those who bear it well all the time. 
Fat children do better without it. In disorders of the stomach, 
and while the appetite is bad, also during a feverish disease of 
any kind, also during a diarrhoea, it must not be given. (See 
pp. 53, 137.) 

Preparations of malt may be administered to advantage in 
small quantities several times daily. It is self-understood that 
the multitude of preparations containing medicines will be left 
by the intelligent practitioner on the shelves of the corner 
pharmacy. 

Tea of walnut-leaves was a universal remedy in scrofulous 
affections when tastes were simpler, medicines less in num- 
ber, and when less money was invested in expensive articles. 
Among the poor, and in country districts, it will prove an ad- 
mirable adjuvant. 

Among medicinal preparations it is those* of iron and iodine 



150 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

which have met with most praise. The indications for the 
administration of the former are those of anaemia. Where this 
is marked, iron ought to be given, and continued for a long 
period, according to the principles and methods laid down in 
a previous chapter. Iodide of potassium, of sodium, and the 
tincture of iodine have been used. In the erethic form of 
scrofula they may do harm, and ought to be avoided. The 
same warning holds good in reference to those children who 
suffer from frequent attacks of bronchitis, which may already 
be the precursor or accompaniment of pulmonary tuberculosis. 
A sensitive stomach will not bear it. It may be made more 
digestible by the addition of a bitter tonic, and particularly by 
a few drops of tincture of nux vomica, diluted, with each dose. 
When the iodide results in bringing on the disagreeable or dan- 
gerous symptoms of iodism, the addition of chlorate of potas- 
sium to the iodide, in doses of from fifteen to thirty grains 
daily, according to age, will prove beneficial. The potassium 
(or sodium) iodide may be taken in five- or six-grain doses, 
daily, by a child of two years, fifteen grains at ten years, for a 
long period. The sodium is better tolerated, as a rule. The 
tincture must not be administered in more than one-drop doses, 
three times a day. The syrup of hydriodic acid is often toler- 
ated better than the previous preparations (two to four cubic 
centimetres = J-l drachm daily). The syrup of the iodide of 
iron is a valuable preparation, to be given three times a day in 
doses varying from three to twenty drops. So is the saccha- 
rated iodide of iron, in three daily doses of from two to five cen- 
tigrammes (gr. -J-f). 

The indications for the use of iodine in general are also 
valid for that of the mineral springs containing that element, 
such as St. Catherine or Kreuznach. Fat children, and those 
with cedematous swellings, glandular infiltrations, or the exu- 
dations resulting from scrofulous inflammations, are mostly 
benefited by them. 

Of phosphorus, as a tissue-builder in subacute and chronic 



DISEASES OF THE BLOOD AND CONSTITUTION. 151 

inflammations of the bones, I have spoken in another connec- 
tion. (See p. 141.) Its property as a stimulant of growth in 
general I have often verified in many morbid conditions. 
Scrofulous tissues, with their rapid decay and new formation, 
exhibit indeed the type of subacute inflammation, with the 
peculiar characteristic of rapid cell-proliferation, which per- 
ishes speedily because it is not sustained by a healthy connec- 
tive tissue. The latter is formed by the internal administration 
of minute doses of phosphorus, such as I recommended for the 
above indications. Thus I refer to the remarks (made pre- 
viously on the subject) on the doses in which the drug is to be 
given, the period during which it is to be continued, and the 
impossibility of substituting for it any of its salts. Those who 
do not pin their faith in the treatment of any disease on any 
single remedy, but combine remedial measures with the proper 
regard to hygiene, will not be mistaken in their expectations of 
the effects of phosphorus in the treatment of scrofulous dis- 
order. I have used arsenic for the same purposes, and on the 
strength of the same indications, but it has appeared to me to 
offer less advantages in these conditions. 

A very active treatment can and should be applied to the 
lymph-bodies. Their tumefaction may be prevented in most 
cases. They swell under the influence of an irritation in the 
neighborhood. An intestinal catarrh will congest the neigh- 
boring mesenteric lymph-bodies; within a few days they are 
enlarged and hyperaemic. When the local catarrh continues 
the hyperemia will result in hyperplasia, and no long period 
is required to so change the tissue as to render the induration 
unabsorbable. If the diarrhoea "of the second summer/' or of 
"teething," had not been permitted to go unchecked, these 
"scrofulous" glands would never have existed, and never inter- 
fered with lymph circulation and nutrition. Or the caries of a 
tooth, or a nasal catarrh, or a facial eczema, or one of the scalp, 
is allowed to continue and develop into a chronic condition, 
and the secondary swelling of the glands round the throat and 



152 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

neck is the irrepressible result. Principiis obsta. The greatest 
and gravest consequences might easily be prevented by attend- 
ing to their trifling causes. 

When the lymph-bodies have had time to undergo indura- 
tion, an attempt should be made at reducing them, though they 
be ever so hard or large. The frequent inunction of iodide of 
potassium ointment made with lanolin will often carry the 
point; so will that of green soap. Which preparations ought to 
be used, and to what extent the remedy, to what the massage of 
the parts alone is effective, is left to the decision of the practi- 
tioner. At the same time the syrup of the iodide of iron may be 
administered internally. 

When these measures have proved inefficient after a reason- 
able time, the indurated lymph-bodies should be removed. The 
operation is not always easy, but recovery is almost certain, 
and the protection afforded by it pays more than fully for 
every exertion on the part of the medical man, and the tem- 
porary annoyance on that of the patient. When an abscess 
forms in the centre of a gland, this should be enucleated. 
If it rupture, all the remaining parts of the lymph-body 
should be scraped out, disinfected, and made to heal. 

Diseased bones should be treated on similar principles. Un- 
less a scrofulous ostitis be superficial and within easy reach, 
the diseased parts ought to be removed with the least possible 
delay. The number of cases recovering, though after a long 
time, and sometimes with shattered general health, without 
an operation, affords no excuse for those which have been per- 
mitted to develop into caries, or necrosis, or pyaemia, or leuco- 
eythasmia, or tuberculosis. 

Scrofulous conjunctivitis, keratitis, otitis, eczema, and ar- 
thritis should be treated internally, and to combat the morbid 
disposition, besides the procedures and appliances taught in 
subsequent chapters. 

That the scrofulous condition requires good air and ventila- 
tion may be mentioned, though it hardly appears necessary 



DISEASES OF THE BLOOD AND CONSTITUTION. 153 

to do so. The children ought to be kept in the open air con- 
stantly. For that purpose the winters should be passed, if 
circumstances permit, in warmer climates. From that point 
of view the summer sea-sanitaria of our large cities, and the 
similar institutions of the civilized countries of Europe, have 
rendered valuable services. 

The skin of a scrofulous child must be kept scrupulously 
clean. But water must do more than merely that: the child 
must get used to cold water, and thereby accustomed to changes 
of temperatures. The principles laid down in connection with 
the bathing of the very young hold good here, and I refer to 
my remarks on the subject. Salt-water is preferable to plain 
water, and sea-bathing to either. Only in the cases of those 
who suffer greatly from eczema and other scrofulous eruptions, 
water must be avoided as long as the surface is not relieved. 
Indeed, no irritation of the surface is tolerated. Thus a 
scrofulous skin ought to be spared adhesive plasters or vesi- 
catories, though the indications for their use be ever so 
tempting. 

Incidental diseases of scrofulous children require more than 
the usual care. The perishable character of all their tissues 
renders an average febrile or inflammatory disease uncommonly 
dangerous. Unexpected deaths are frequently met with in 
such cases. In them the avoidance of strong purgatives, or 
depletions, is the first commandment; in them early feeding 
and sufficient general stimulation are among the principal 
indications; in them cardiac tonics, given timely and plenti- 
fully, will save many a life that would otherwise succumb. 

4. Lympliatism. 
A number of infants and children exhibit a peculiar pallor, 
coupled with adiposity and rhachitical symptoms. I have 
alluded to this form of rhachitis repeatedly during many years. 
These patients, always pale and flabby, show a singular general 
debility. The laryngismus found in such children, with or 



154 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

without sudden death, like the other symptoms, glandular 
swellings, etc., I mostly attributed to this form of rhachitis; 
probably correctly, at least in many or most instances. Maybe 
others should be explained differently. 

"Lymphatic state" has been called a condition of pallor, 
adiposity, hyperemia, but otherwise normal structure of most 
organs, rather large (sometimes very large) spleen, thymus, and 
also thyreoid, rhachitical epiphysitis, swelling (in different de- 
grees) of the lymph-bodies of the neck, axillae, mesentery, of 
the tonsils and the follicles of the naso-pharynx, and of the 
tongue. This condition is also complicated with hypoplasia of 
the heart and arteries (Virchow, different from actual rhachi- 
tis, in which the arteries are rather large), which explains many 
a case of chlorosis, and also of haemophilia, sometimes with 
infantilism of the sexual organs, hairless pubes, and lympho- 
cytosis. Sudden deaths seem frequently to be due to this condi- 
tion, or rather to the excessive weakness of the heart connected 
with it (Paltauf, Escherich, J. Ewing). Escherich tried the 
effect of calf-thymus feeding in this complex ailment, with 
negative result. Besides general antirhachitic treatment I 
should feel like relying mainly on phosphorus. 

In some cases of general lipomatosis of children of both 
sexes, I was struck with the smallness of their radial and 
carotid arteries and their feeble heart-beats. The percussion of 
the heart yields very questionable results, on account of the 
large diameter of the chest walls. Still, this was never so thick 
as to prevent the percussion of the thymus behind the manu- 
brium sterni. In several instances it was found to be large, 
in patients of ten and twelve years. In every one of its 
varieties lipomatosis, being general, is a serious danger in any 
intervening disease. All the organs, mainly the heart, being 
liable to be incompetent, stimulants and roborants should be 
given through the whole course of feverish diseases, intervening 
in excessively adipose children. Intertrigo is very common 
and obstinate. 



DISEASES OF THE BLOOD AND CONSTITUTION. 155 

The diet should be principally albuminous, with a fair 
amount of fat, and very little vegetable hydrocarbons, and little 
water. General massage, exercise, a dose of sodium sulphate 
every morning, and iodide of iron are helpful. Thyreoid may 
safely be given, with some caution and combined with a car- 
diac stimulant (strychnine), to advantage. In hydremic anaemia 
also, with or without a slight enlargement of the thyreoid, and 
in marked simple anaemias, with or without enlarged spleen, be- 
sides lipomatosis, thyreoid is recommended by N. Koplik (Arch, 
of Ped., July, 1897). 

5. Diseases of the Ductless Glands. 

Their "internal secretion" is required in the organic economy 
either as an additional element, or for the purpose of destroy- 
ing the toxic results of metabolism. 

Diseases of the thyreoid gland are not often observed in in- 
fancy and childhood; still, even carcinoma and tuberculosis 
have been noticed. Syphilitic gummata have been found, and 
would, if diagnosticated, demand specific treatment. A der- 
moid tumor was removed from an infant two hours old, who 
recovered (London Lancet, May 22, 1897). Atrophy with myxoe- 
dema has been reported in a girl of twelve years; its treatment 
consists in the administration of thyreoid gland. Inflammation 
has been known to follow trauma and infectious or common 
catarrh of the nose and naso-pharynx. The treatment should 
consist of local applications of ice, hydrotherapeutic measures 
in general, saline purgatives, irrigations (both cleansing and 
antiseptic) of the nares and pharynx, and perhaps iodine both 
internally and externally during slow absorption. Goitre — 
struma — is mostly met with in the lateral lobes, and therefore 
is not liable to annoy respiration until it becomes very large; 
should it do so, it compresses, particularly when behind the 
sternum, the trachea, vessels, and nerves. The usual forms 
found in the adult (lymphatic, cystic, even colloid and fibrous) 
are observed. When congenital, it is apt to be absorbed; the 



156 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

age of puberty also predisposes to spontaneous decrease. Most 
eases presented were in children from seven to ten years old. 
An occasional pulsation is not, of itself, pathognomonic of 
Graves's disease. An epidemic — infectious and contagious — 
form of goitre has been observed in schools, but was only a 
temporary ailment. Tincture of iodine, strong or modified, 
may be applied once every few days, or iodide of potassium in 
glycerin (1 : 2-8), or a potassium iodide ointment with lanolin 
(1 : 4-10) may be rubbed in several times daily. Potassium 
iodide may be given in doses of from five to fifteen grains daily. 
AVith iodide of potassium injections into the tissue of the en- 
larged gland I have had no experience. The cystic form re- 
quires puncture with injection of Lugol's solution; if the 
secondary swelling be too large and annoying, ice should be ap- 
plied. Or the cyst, or cysts, may be incised and tamponed with 
aseptic gauze. If extirpation be preferred, it must not be total, 
because of the consecutive occurrence of cachexia strumipriva, 
tetany, and myxcedema. 

Extirpation has the same effect which is observed in cases of 
absence or of degeneration of the thyreoid gland. This degen- 
eration may lead to atrophy or to an apparent hypertrophy; 
that is why thickness of the thyreoid should not be taken for the 
presence of normal tissue. Myxoedema (mainly characterized 
by that condition of the thyreoid, by the peculiar myxomatous 
structure of the skin and subcutaneous tissue, and by mental 
failure) is seen in the young as well as in the adult. In the 
young it is mostly complicated with cretinism or semi-cretinism; 
in many cases the absence or degeneration of the thyreoid may 
be its only cause, in many others it exhibits at the same time 
changes in the skeleton, prominent among which is the 
shortening of the cranial base produced by the premature ossi- 
fication of the occipito-sphenoidal synchondrosis. Thus, with 
the exception of the latter, the cretinism of the foetus and in- 
fant and the myxoedema of the young and of the adult are the 
results of the same anomaly. 



DISEASES OF THE BLOOD AND CONSTITUTION. 157 

This cretinism is by no means so rare among us as it has been 
reputed to be even among the best observers. The patients 
with their thick, short neck, clumsy-looking head, retracted 
root of nose, wide-apart eyeballs, thick lips and tongue out- 
side the teeth, large abdomen and dwarfed stature, and their 
indolence seldom turn up in practice. They are occasionally 
found in the retreats of the tenement houses, where the general 
practitioner may happen to see them, though he be not con- 
sulted about them; only of late they turn up in the dispensaries. 

In the therapeutics of cretinism in most of its forms the thy- 
reoid gland, in its various preparations, has worked a beneficial 
revolution, as it also has in that of myxcedema. This addition 
to our facilities for overcoming a formerly incurable ailment, 
at least to a certain extent (for no perfect recovery is known as 
yet), is, as Meltzer has so well shown (New York Med. Monats- 
schrift, May, 1895), eminently due to biological experiment and 
to it only. There are but few cases that resist its efficacy. The 
doses, however, must be small, particularly in the beginning; 
from one-third of a grain to one grain of Parke, Davis & Co.'s 
powdered thyreoid three times a day, the small doses first, the 
larger one afterwards, are all that ought to be given an infant or 
child, according to age. The treatment must be continued a 
long time. It cannot be expected to act so well as in the myxce- 
dema of the adult, because the cretinism or semi-cretinism of 
the child is the result of an arrest of development at a very early 
period of intrauterine life. It follows that the treatment ought 
to begin as early as the diagnosis can be made. Besides the pow- 
der of Parke, Davis & Co., I know only Armour's preparation 
and the tablets of Burroughs and "Wellcome. They are not of 
equal strength, and in every case ought to be commenced with 
in small doses; for sometimes even apparently small doses pro- 
duce general and cardiac irritation, palpitation, tremor, de- 
bility, and diarrhoea. Other effects of the thyreoid medication 
are obtainable in the child as in the adult. Myxcedema, the 
near relative of cretinism, shows its main symptoms in the sud- 



158 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

cutaneous tissue, in the skin, and in the nervous system. I have 
seen good results of the thyreoid treatment in cases of excessive 
adiposity, — one boy of eleven years, weighing one hundred and 
fifty pounds, was reduced to one hundred and twenty in four 
months under the use of small doses, — in scleroderma, and in 
a case of psoriasis. Fortunately, all such cases are rare. 

The attempts at isolating the active principle, either organic 
or probably chemical, have not yet proved successful. Neither 
the iodothyrin of Baumann nor the thyreoantitoxin of Fraenkel 
have given uniform satisfaction. The latter is recommended 
in doses (to an adult) of one centigramme (gr. J), five or six of 
which may be given daily. 

Not infrequently have I combined arsenic, or phosphorus, 
with the thyreoid, some of the cases of cretinism showing char- 
acteristic symptoms of rickets. Indeed, the condition of the 
base of the skull appears to be one of the manifestations of 
localized rhachitis which has completed its entire course before 
birth. 

The rapid effect of thyreoid administration is rather jeopar- 
dized by the necessity of persisting in the treatment, in 
order to escape relapses. Horsley's attempts at transplanting 
glandular substance will have to be repeated until they will 
be successful, and place the effect of the miraculous therapy 
beyond any risk. Such risks there are now. The effect, some- 
times of small doses, may be distressing, — prurigo, perspiration, 
tachycardia, delirium, even tonic spasms, and undesirable loss 
of weight. In all these symptoms the effects of the treatment 
resemble very much those of exophthalmic goitre (Graves's or 
Basedow's disease) in which the thyreoid is enlarged, and, in 
all probability, the seat of abnormal functions. I treat of it in 
this connection, instead of giving it, as I did in the first edition 
of this book, a place among the vascular neuroses. 

Exophthalmic goitre is not a frequent disease in childhood. 
Of twelve cases reported in literature until 1879, four were 
mine (New York Medical Record, July 5, 1879); they occurred 



DISEASES OF THE BLOOD AND CONSTITUTION. 159 

in children of from nine to thirteen years. Nor are the symp- 
toms so grave as they are liable to be in the adult; in many, 
not all of the three alterations (exophthalmos, goitre, and 
tachycardia) are found at the same time. In the treatment 
proper regard must be paid to diet and hygiene. Xo excite- 
ment, fear, work, stimulants. Prolonged or but partial rest in 
bed at home or in a hospital. Baths of moderate temperature. 
Ice to the heart and (or) to the goitre for days, or hours, in 
succession. Application once or twice daily of a mild galvanic 
current (negative pole, from one to three milliamperes) from 
five to ten minutes over the sympathetic nerve, between the 
horn of the hyoid bone and the sterno-cleido-mastoid mus- 
cle. Digitalis acts badly, and is apt to increase tachycardia; 
strophanthus and iodide of potassium act more favorably. 
Gowers recommends belladonna in rising doses. My most suc- 
cessful medicinal treatment has been with arsenous acid, from 
two to six milligrammes (one-twentieth to one-tenth grain), 
atropine from one-third of a milligramme to one milligramme 
(one one-hundred-and-eightieth to one-sixtieth grain), and ex- 
tract of ergot a gramme (grs. 15) daily. I lately had a child's 
case under observation for some time, and was favorably im- 
pressed with the effect of thyreoid in that case. Possibly it acts 
better in children in whom the course of the disease is mostly 
milder; for, as far as adults are concerned, experience does not 
seem to be favorable. It is quite possible that Graves's disease 
will be much more influenced by the administration of thymus 
gland. Eeinbach found fresh thymus to act in cases of goitre, 
in which thyreoid treatment had proved ineffective. The direct 
dependence of Graves's disease on the condition of the thyreoid 
glands appears to be proven by the result of operations (partial 
removal), which, according to Oppenheimer, cured eighteen and 
improved twenty-six out of sixty-six cases. Nine died within 
a day. Of late the results of operations are greatly better; 
Kummell, for instance, operated on fourteen severe cases of 
exophthalmic goitre with partial removal of the thyreoid gland; 



160 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

twelve were permanently cured. The report was made from 
two to seven years after the operation. The remaining part of 
the gland showed a tendency to shrink, in one case only it grew 
a little larger. The other two cases were cured, with the excep- 
tion of the exophthalmos, which persisted at first, but gradually 
diminished in size (Berl. Klinik, June, 1897). Doyen reported 
two equally successful cases (Sem. Med., 1897, p. 280). 

Further favorable results of the thyreoid treatment may be 
mentioned here. It is said to have improved dwarf growth, 
akromegaly, hyperplastic otitis interna in young obese persons, 
and psoriasis (besides prurigo); the absence of thyreoid func- 
tion certainly injures the growth of bones, while it seems to 
leave intact the large abdominal viscera. It has sometimes 
improved tetany and certainly has a very favorable effect in 
simple hyperplastic goitre, in which the normal structure of the 
gland has been destroyed. 

Diseases of the thymus gland are not yet amenable to treat- 
ment. Inflammations, abscesses, syphilis, tuberculosis, sar- 
coma, lymphadenoma, and carcinoma have been observed. Its 
physiological dignity in the fcetus and young infant is cer- 
tainly great. Nearly forty years ago Friedleben proved that it 
is indispensable in the foetal and infant economy. It is largest 
(normally) from the third to the twentieth month; about the 
ninth month it was found, in abnormally large cases, 1.5-2 
centimetres in thickness. As the distance between the manu- 
brium sterni and the vertebral column is but two centimetres 
about the eighth month of life, the slightest increase of an en- 
larged thymus through disturbed circulation, by crying or 
otherwise, may prove suddenly fatal. 

Another danger is the irritation of the recurrent nerve by the 
constant up-and-down movement of the thymus gland. 

Koenig extirpated a part of the thymus of an infant of nine 
weeks that suffered from intense dyspnoea. The remaining 
part he attached to the manubrium sterni and the tendons of 
the sterno-cleido-mastoid muscles; recovery was complete in 



DISEASES OF THE BLOOD AND CONSTITUTION. 161 

four weeks. Thus, local pressure or irritation by the greatly 
enlarged gland may prove fatal, though most cases of sudden 
death in laryngismus stridulus must be explained otherwise. 
A recent case of death from large thymus occurred nine hours 
after birth (Schleif). 

Like the thyreoid, the thymus was found enlarged in many, 
according to Erb in all, cases of akromegaly. 

Acromegaly, enlargement of all the tissues — except skin — of 
hands and feet, of both maxillae, with alveolar processes, of ears, 
tongue, and thorax, was attributed by Marie to hyperfunction 
of the hypophysis (pituitary gland), which is in part a secreting 
organ without a duct, so that the lymph-vessels carry off the 
secretion. Marie, therefore, looks upon akromegaly (and many 
cases of gigantic growth, — several professional giants were 
found to be akromegalic) as a nutritive disorder connected 
with an anomalous hypophysis, as myxcedema is with the thy- 
reoid gland. Possibly, as the thymus appears to be affected, 
akromegaly is the result of the complex anomalies of several 
organs. The treatment with hypophysis gave no conclusive re- 
sults; nor that with thymus. The latter was also employed by 
Macalister in pseudohypertrophy, and Mikulicz in goitre and 
Graves's disease; in the latter it has also been used by Owen, 
Cunningham, Edes, and Solis-Cohen. X. Mackenzie reported 
twenty cases treated with thymus (Amer. Joum. of Med. Sc, 
February, 1897). One died, six showed no improvement, thir- 
teen showed some improvement, which, however, was not con- 
sidered marked or conclusive. 

Addison's Disease. — The "suprarenal melasma" depends on 
anomalies (tuberculosis, carcinoma, induration, hemorrhage) of 
the adrenals. In some cases the semilunar ganglia have been 
charged with being its cause. Great muscular weakness, de- 
bility of the heart, frequent and small pulse, irritability, later 
apathy, cephalalgia, exhaustion (together with the character- 
istic discoloration of the skin) are the symptoms common to a 
number of constitutional ailments leading to a slow death. The 

11 



162 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

treatment is therefore, to a great extent, that of the anaemias, 
and requires iron, arsenic, strychnine, and measures directed 
against incidental symptoms, such as diarrhoea. Adrenals have 
been given in powder or in glycerin extract, or cooked.* The 
equivalent of two glands was administered by Osier, with vary- 
ing results; he has a case (adult) that gained fifteen pounds in 
six weeks and felt stronger ("Princ. and Pract. of Med.," 2d 
ed., 1895, p. 749). 

Most valuable general information on organotherapy we 
owe to Hun, and lately (Amer. Journ. of Med. 8c, July, 
1897) to Kinnicutt, who gives the results of vast experience 
and large numbers. According to him, in accordance with 
other observations, the myxoedema of cretinism is readily re- 
moved by thyreoid treatment. The earlier it is commenced in 
the young the greater is its influence on growth and mental 
development. In the idiot, with rather more a lymphatic than 
a myxoedematous condition, improvement is also obtained. 
Hyperplastic goitre (not the cystic) is greatly improved if not 
cured. Exophthalmic goitre was not improved; on the con- 
trary, many patients felt worse. Obesity is influenced rapidly, 
losses of from two to eleven pounds having been observed; 
these losses will continue for some time only. Psoriasis is in- 
fluenced to a certain extent only; the thyreoid treatment seems 
to have no better effects than others. Other skin-diseases were 
not particularly benefited. Of forty-eight cases of Addison's 
disease treated by suprarenal extract, six were cured, twenty- 
two improved, eighteen not improved, and two aggravated. 
Thymus extract appears to be useless in exophthalmic, benefi- 
cial in hypoplastic goitre. Of thirty there was improvement in 
twenty, a cure in two. Pituitary preparations were used in 
thirteen cases of acromegaly. Varying degrees of improvement 
were noticed in seven, none in five, and one became worse. In 
one the affected extremities decreased, in two the pain in the 
head and the limbs diminished. 

* Literature in E. Merck's Annual Report on the Year 1896. 



DISEASES OF THE BLOOD AND CONSTITUTION. 1G3 

6. Hemorrhagic Diathesis. 

Under this head I propose to treat of purpura, the hemor- 
rhagic disease of Werlhof, scurvy, poliosis rheumalica, and 
hemophilia, because of their similarity of symptoms and their 
— to a certain extent — uniform anatomical cause. Among 
them all, the first, with its wide-spread petechia? and subcutane- 
ous and cutaneous hemorrhages, is most frequently mentioned. 
It results from all causes interfering with general nutrition, 
and particularly with that of the blood-vessels. Among them 
are poverty, uninhabitable dwellings, chronic gastro-intestinal 
catarrh, dysentery, typhoid fever, diabetes, miliary tuberculosis, 
pneumonia, diphtheria, scarlatina, and measles. Relapses are 
very common. The complications with hemorrhages from the 
mucous membranes of the nose, stomach, and intestines, from 
the kidneys, into the brain and retina, and often with fever, 
are denominated Werlhof s disease. The diagnosis of "scurvy" 
requires bleeding from the gums, "peliosis" complications with 
"rheumatic" pain and swelling of the joints, but without an 
affection of the heart, and haemophilia the hereditary tendency 
to bleeding of (mainly) the male transmitted through the 
female, on the bases (Virchow) of narrowness of the arteries 
and insufficient development of the thin blood-vessel walls. 

The alleged defective condition of the blood does not explain 
the hemorrhagic tendency. No blood, though ever so thin, 
penetrates a healthy blood-vessel wall. Hydremia by itself 
does not produce bleeding without an impaired condition of 
the tissue of the blood-vessel; thus it is that the same degree 
of anaemia in women may result in metrorrhagia in one, in 
amenorrhcea in the other. Infants are peculiarly liable to 
bleed, because in them the blood-vessel tissue is still unde- 
veloped; the embryonic condition extends into early infant 
life, and gives rise to frequent hemorrhages into the brain, 
meninges, and other serous membranes. "When morbid influ- 
ences are added to this physiological predisposition, the result 
is easily comprehended. 



164 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

These influences are unknown. Bacteriological explanations 
are not yet quite satisfactory; still it is possible that all these 
varieties of hemorrhagic diathesis, which have been subsumed 
by Wm. Koch under the common heading of "scurvy," are 
more or less acute infectious diseases. That suspicion appears 
particularly justified in regard to the purpura fulminans, a 
few cases of which have been observed in the very young 
(Henoch). 

The treatment is to a great extent preventive. The social 
condition of a large part of the population is a main cause and 
ought to be improved. Thus the successful treatment depends 
largely on the prosperity of all, and is another proof of what 
ought to be considered a fact, that medical and social questions 
and aims are frequently identical. Zymotic disorders and erup- 
tive fevers should be treated with a view of sustaining the 
strength of the system and the vigor of circulation. The 
heart's action ought to be watched constantly, and cardiac 
tonics given before heart-failure sets in. The dietetic treat- 
ment of these diseases is at least as important as their medi- 
cinal management. In this way hemorrhagic diathesis is kept 
off, as well as exhaustion. 

Medicines can accomplish a great deal, but ergot less than 
it is often credited with. In these conditions I have often met 
with its untoward influence on digestion, and but rarely with 
a favorable influence on the hemorrhagic deposits or processes. 
Perhaps hydrastis does better. Iron also does not appear to 
yield desirable results; among its preparations the tincture of 
the chloride is perhaps the best; the tincture of the malate and 
the liquor of the albuminate are well tolerated. Digitalis has a 
favorable effect on the heart's action; an infant of a year may 
take the equivalent of from one to four grains daily for some 
days, two grains daily afterwards. "With it may be combined 
strychnia; the same baby may take a fiftieth of a grain daily. 
As relapses are quite frequent, the invigoration of the blood- 
vessels is the main object in view. From one to three drops of 



DISEASES OF THE BLOOD AND CONSTITUTION. 165 

Fowler's solution, largely diluted, may be given every day for a 
long time. Better still is phosphorus, the method of whose 
administration, and the doses of which, have been detailed in 
a former chapter. Lead and tannin have not satisfied me at all. 
Local hemorrhages, when accessible, will require the applica- 
tion of ice, or compression of the bleeding vessel. The solution 
of antipyrin (5-20-50 per cent.), with or without tannic acid, 
is a good styptic. The success of the preventive treatment of 
haemophilia will be rather doubtful as long as individuals are 
not controlled by the community in regard to the demands of 
public health. The daughters of hasmophilic families ought to 
be prevented from, and protected against, contracting mar- 
riages and having children. Phosphorus, administered in small 
doses and continued a long time, seem to diminish the tendency 
to bleeding. 

Infantile scurvy ("Barlow's disease") has become very amen- 
able to treatment, both in its early and in its advanced stages. 
Its main and characteristic symptoms are pain and immobility 
of the (mostly lower) extremities, swelling (mainly) of the 
diaphyses depending on subperiosteal hemorrhages, petechias, 
and ecchymoses over any part of the skin, particularly of the 
eyelids, spongy condition and purple color of the gums, no mat- 
ter whether teeth have appeared or not, and sometimes separa- 
tion of an epiphysis. These symptoms are frequently compli- 
cated with the tumefied epiphyses and other marks of rhachitis. 
The prognosis is good. The principal remedy is fruit-juice, that 
of from one-half to two oranges a day, or of a pineapple; it is 
the specific. Complications with rhachitis require, besides, the 
elixir of phosphorus. Sterilized milk, if the only nutriment, 
as in many instances it will be found to have been, should be 
banished. If no reliable sweet milk be accessible, it should be 
pasteurized and combined with cereal (barley, oatmeal) decoc- 
tions, and meat broths, or some meat-juice should be adminis- 
tered as a regular food. 



166 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

7. Diabetes. 

Diabetes mellitus is by no means a common disease among 
infants and children, but it is not so rare as some will have 
it, nor so frequent as those assert who have found glycose in the 
urine of infants whose food was supplied with an unusual 
quantity of sugar. Indeed, traces of sugar are often met with 
in the urine of nurslings. But this is not "diabetes." 

In the ten years before 1860 there were thirty-one deaths 
from actual diabetes in Great Britain in children under fifteen 
years, annually. Since that time the occurrence of the disease 
in every period of life appears to have increased considerably. 
Hereditary and family influences, such as neuropathies, epi- 
lepsy, insanity, syphilis, exert a great influence. Caron reports 
the cases of three children of the same mother, at the ages of 
three and a half, and one and a half years, and of three 
months. Hydrocephalus, injuries to the head, colds, atrophy 
of the pancreas, dysentery, morbus maculosus, measles, and 
scarlatina are referred to as causes. In most of the cases which 
have come under my own observation I could not elicit a cause. 
The highest percentage of sugar I have noticed in a child (boy 
of four years) was six and one-half. Heubner observed eight 
and one-half, with a daily quantity of five thousand grammes, 
or five quarts, Leroux ten and a half. The prognosis is not so 
good as Eedon and a few others appear to believe. Twenty 
years ago Kulz reported six recoveries in one hundred and 
eleven, Wegeli, thirty-nine in one hundred and eight cases. 
I am afraid the diagnosis was obscured by the facility with 
which copper is reduced by creatinin, creatin, and other con- 
stituents of the urine. Therefore, several (different) tests 
should be employed, when dry skin, emaciation in spite of 
ravenous appetite, polyuria with high specific gravity (up to 
1044), also furunculosis, are noticed. The disease runs a more 
rapid course in infants and children than in adults, and termi- 
nates more readily in coma and death. I never saw a recovery 
in more than fifteen cases. Therefore the treatment must be 



DISEASES OF THE BLOOD AND CONSTITUTION. 167 

circumspect and energetic. Strict antidiabetic diet should be 
enforced. Fortunately, the young, with very rare exceptions, 
are apt to live mostly on milk, which may be given copiously 
in any shape. Thus less difficulties are encountered in them 
than in adults. For these also milk, skimmed or not, forms a 
principal and beneficial part of their nutriment. Saccharin 
or glycerin may be used instead of sugar. "Gluten bread" 
contains too much starch, the "aleuronat" of the Germans 
about half as much as common bread. The medicinal treat- 
ment of the young requires some modifications. The facility 
with which cerebral symptoms ("coma") are developed, ren- 
ders the persistent use of alkalies advisable (mineral waters), 
mainly the sulphate of sodium. Opium is tolerated in increas- 
ing doses. Iodoform, which I have seen to render fair service 
in adults, in daily doses of from ten to twenty grains internally, 
is seldom tolerated by the young, even in proportionately small 
doses. Arsenic may be given in increasing doses a long time, 
the bromide as well as other preparations; one drop and more 
of Fowler's solution, largely diluted, after meals, three times 
daily, the dose to be increased gradually until doses of from two 
to four drops are taken. As in every disease which resists treat- 
ment to an unusual degree, a large number of other medicines 
have been recommended. As this book is not a library, but 
written for practical purposes only, I abstain from enumerating 
drugs which I believe to be useless. There is one, however, 
which, in connection with everything destined to improve di- 
gestion and assimilation, appears to have a very favorable influ- 
ence on the diabetic process. Salicylate of sodium, with an 
alkaline beverage (Selters, Yichy), has a decidedly favorable 
effect. A child of five years may take from five to eight grains, 
three times a day, and continue its use for many weeks, to ad- 
vantage. Lactic acid (cantani) may be tried with equal parts of 
bicarbonate of sodium in water, one or two grammes a day (srs. 
15-30), lactate of calcium in the same or larger doses. Ex- 
tract of jambul has been powerless in my hands, benzozol in 



168 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

daily doses of half a gramme or more (gr. 10) nearly so. Anti- 
pyrin appeared to be a little more efficient, the feeding with 
pancreas not at all. The prognosis was always bad when oxy- 
butyric acid or renal casts made their appearance. Tubercu- 
losis is not so frequent as in the adult. 

Diabetes insipidus is a rare disease, but more common than 
diabetes mellitus. A large amount of urine of a low specific 
gravity (1000 \ to 1005) is secreted daily. The increased mic- 
turition, great thirst, and emaciation are among the prominent 
symptoms. In some cases there appeared to be a hereditary 
influence. Syphilitic and other brain lesions, and injuries, 
have been found to explain its occurrence. In one case of mine, 
that of a girl of five years, it ceased, together with a copious 
and constant salivation, after the removal of a taenia medio- 
canellata. Inveterate masturbation and consecutive "neuras- 
thenia" appeared to be the cause of the excessive flow of urine 
in several children of from four to eight years. It ceased gradu- 
ally with the restoration of correct habits and better general 
health. Of the remedies which have been recommended, I men- 
tion valerian, valerianate of zinc, bromides, salicylate of sodium, 
and galvanization of the head. All of these proved unsatisfac- 
tory in my hands. But I have seen good results, and sometimes 
speedy improvement, from the administration of ergot and 
atropia. In other cases they were absolutely useless. A child 
of five years may take daily, of the former two cubic centime- 
tres (half a drachm) or more (extr. fluid, or the corresponding 
amount of ext. ergot., or ergotin), of the latter one-hundredth 
of a grain or less (one-half of a milligramme). More reliable 
than either has been strychnia, in three daily doses of one-hun- 
dredth of a grain each, or more (one-half of a milligramme). 
Valerianate of zinc may be tried in daily doses of half a gramme 
to one gramme (grs. 7-15). Opiates are highly recommended 
by Bouchut; pilocarpine, antipyrin, and acetate of lead by 
others. Fortunately, the prognosis is much more favorable than 
that of diabetes mellitus, particularly in hereditary cases. 



V. 
INFECTIOUS DISEASES.* 

1. Tuberculosis. 

In ten hundred and forty-five autopsies made in the New 
York Foundling Hospital (Northrup) and the Babies Hospital, 
all of which were reported by L. Emmett Holt, tuberculosis was 
found in fourteen per cent.; altogether one hundred and nine- 
teen cases. These and similar statistics demonstrate the fre- 
quency of tuberculosis in infancy. In the first year of life, in 
the second, and in the period from the second to the fifth year, 
it is the same. In the above one hundred and nineteen cases 
the lungs were affected one hundred and seventeen times, the 
pleura sixty-nine, the bronchial lymph-nodes one hundred and 
eight, the brain forty, the liver seventy-seven, the spleen 
eighty-eight, the kidneys forty-six, the stomach five, the intes- 
tines forty, the mesentery thirty-eight, the peritoneum ten, the 
pericardium seven, the endocardium one, the thymus three, the 
adrenals three, and the pancreas three times. 

In the young, as in the old, tuberculosis is spread either by 
mechanical transmission through cough, deglutition, and aspi- 
ration, or in the contiguity of tissues after having been devel- 
oped in a given locality, or through lymph-ducts and blood- 
vessels. The latter, after having absorbed bacilli from the 
primarily invaded part, are liable to distribute them in a distant 
locality or all over the system in the shape of acute miliary tu- 

* With the exception of a very few (intermittent fever, rheumatism) 
all the diseases enumerated under this head are also directly or in- 
directly contagious. As it is not my intention to systematize closely, 
they all appear in this chapter indiscriminately. 

169 



170 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

berculosis. Most frequently the primary seats of the affection in 
the young are the bones, joints, and lymph-bodies ("glands"). 
Among the latter, those of the mesentery are by no means so 
frequently affected as they are still reputed to be; those of the 
neck and mediastinum are more subject to early infection. 

Bacilli may be swept into the circulation through healthy 
epithelia, but the majority of infections are the results of a 
morbid condition of the integuments, either epidermoid or 
mucous. Wounds facilitate the admission of bacilli (circum- 
cision, eczema, not vaccination). The nose, the pharynx when 
sore or ulcerated, may be equally dangerous. 

The most common forms in which tuberculosis makes its ap- 
pearance in the young are acute miliary tuberculosis, acute or 
subacute caseous pneumonia, and genuine chronic tubercular 
phthisis with cavities. Caseation, however, does not always 
mean tuberculosis; for it is also met with as the final trans- 
formation of pus, of carcinoma, and of typhoid infiltrations. 
Tubercular abscesses of the lungs are not at all frequent, but 
we see them at every age. While I have met with but very few 
cases before the end of the first year, they are not quite rare 
after the sixth or eighth. Pulmonary tuberculosis is often ac- 
companied or preceded by pleurisy; indeed, it appears probable 
that this pleurisy, with its frequent relapses, is the primary 
seat of tuberculosis in many. 

The most common form of pulmonary tuberculosis in the 
young is that which is developed out of caseous pneumonia. 
It is a frequent result of bronchitis and catarrhal pneumonia 
attending measles and whooping-cough, and is quite generally 
accompanied with considerable changes in the neighboring 
lymph-bodies. It is often seen in the lower lobes; indeed, 
what is frequently suspected to be pulmonary tuberculosis of 
the upper lobes is apt to be induration, resulting from intersti- 
tial inflammations, which retract the corresponding part of the 
chest, exhibit diminished respiratory murmur, prolonged ex- 
piration, and dulness on percussion, and may last a long life- 



INFECTIOUS DISEASES. 171 

time without endangering life or health to any considerable 
extent. 

What I said about the mode of development of these fre- 
quent forms points at once to preventive treatment as the 
principal indication. If bronchitis, catarrhal pneumonia, 
measles, whooping-cough, and glandular diseases are frequent 
causes of tuberculosis, those primary affections must be effectu- 
ally treated. There is no bronchitis which cannot be made 
milder, many a case of catarrhal pneumonia may be shortened 
or rendered less dangerous, and most, perhaps all, cases of 
whooping-cough modified and shortened. In a former, chapter 
I insisted upon the necessity of watching and treating all 
the self-limited diseases. The sin of omission is as grave 
as that of commission. And in my remarks on scrofula, to 
which I here refer, I pointed out the facility of eradicating 
the coming evil by removing the unabsorbable tumefaction of 
lymph-bodies. Unfortunately, the success of treatment in 
cases of acute miliary tuberculosis is so small, and of 
chronic tuberculosis so unsatisfactory, that the indications for 
preventive treatment are the more urgent. The facts of uni- 
versal tuberculosis arising from a local source cannot be denied, 
having been proven by thousands of experimental and clinical 
observations. Now and then a case is quite demonstrable. A 
few years ago I had a little girl in my division in Belle vue 
Hospital who suffered from the most exquisite and extensive 
tuberculosis of the skin I have ever seen. She finally died with 
empyema and general tuberculosis. Coming from a fairly 
healthy family, she developed a glandular swelling in her right 
axilla, which was neglected, and permitted to break spontane- 
ously and result in sinuses. From that place the lymphatics 
transported the accidental bacillary infection, and produced 
extensive ulcerations over the chest; metastases took place in 
other parts of the body, and the child died of universal tubercu- 
losis. It is of no account to investigate whether the original 
affection was tubercular already, or whether the tubercular 



172 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

character was developed afterwards. This much is certain, that 
the child need not have died if the gland which was primarily 
affected had been extirpated. 

It is unnecessary to add that tuberculosis of the bones and 
joints, so frequent in infancy and childhood, requires prompt 
attention, and in some cases operative procedures. 

Among the causes of tuberculous consumption which makes 
its appearance in otherwise healthy persons, both young and 
old, the following also are given prominence by all observers of 
note: Insufficient supply or change of air, absence of exercise, 
overwork without rest or vacation, monotonous food, and in 
larger children persistent mental emotions. Most of these 
sources of disease act as well on the young as on the old, and 
may lead to infiltration, before there is any cough, but anaemia, 
muscular debility, and loss of appetite only. Therefore tuber- 
cular infiltrations are frequently found among the inmates of 
prisons, particularly those who have been isolated a long time, 
workmen in factories, soldiers in barracks, students in semi- 
naries, children in orphan asylums and large boarding-schools, 
those attending crowded public schools and overworked in their 
private studies, besides being crippled by unwise discipline, 
which requires absolute immobility, and by loss of time or op- 
portunity for exercising. It is not very probable that the occa- 
sional stately promenades of the young by couples — though not 
handcuffed, though on a Madison Avenue sidewalk, though 
attended by the good-will, moral character, and Argus eyes of 
two elderly ladies — are equivalents for the free and unham- 
pered play and development of the growing organs. If it be a 
fact that there is so much less tubercular disease among hun- 
ters, farmers, gardeners, and sailors than among factory men 
and women of all trades, school-masters, and tailors, it is cer- 
tain that rowing, skating, gymnastics, and tennis, even the so- 
called calisthenics, if practised in the open air, would expand 
many a child's chest, aerate his blood, keep his organs vigorous, 
and eliminate invading poisons. 



INFECTIOUS DISEASES. 173 

There are many other causes or influences creating or in- 
creasing the possibility of tubercular invasion. A considerable 
predisposition is created by the vulnerability and fragility and 
cedematous infiltration of scrofula; by the catarrh produced by 
sedentary life and foul inhalations. Koch has proved that 
active bacilli pass the stomach unmolested and may infect the 
intestine under unfavorable circumstances, thus rendering even 
a primary intestinal tuberculosis possible. 

While direct heredity is rare, hereditary predisposition to 
tuberculosis is quite frequent, and is transmitted even by such 
parents as appear to be in fair health. Constitutional parental 
disorders resulting from the influence of scrofula, rhachitis, and 
even syphilis, may finally become manifest in the children in 
the shape of tuberculosis. In such children every catarrh must 
be carefully watched. The premature ossification of the costal 
cartilages, most frequently found about the superior part of the 
chest, and the consecutive shortening of the sterno-vertebral 
diameter give rise to contraction of the thorax and insufficient 
expansibility of the (upper lobes of the) lungs. In such cases 
the aeration of the blood suffers at a very early date, catarrhal 
and inflammatory thoracic diseases are liable to become dan- 
gerous, and gymnastic exercises are required in early child- 
hood. 

Direct transmission from the diseased parents to the children 
is probably more frequent than is commonly believed, and 
therefore the child should not share the room and bed of the 
consumptive. Kissing must be omitted under these circum- 
stances; it may often be the cause of contagion, though, per- 
haps, not so frequently as, for example, diphtheria is trans- 
mitted in that manner. 

The origin of pulmonary consumption is uniformly, in almost 
all instances, attributed to the inhalation of bacilli. As they 
are deposited on bedding, clothing, and on the floors and walls 
of rooms, in handkerchiefs and towels, where they get dry and 
disintegrated mechanically, nothing appears to be easier than 



174 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

that the long-lived microbes should be admixed to the dust of 
the room, and thus be inhaled. In this way the contagion of 
acute exanthems is certainly disseminated. Tubercle bacilli, 
like everything solid, when floating in motionless air, is certain 
to sink gradually, and the inference is that children are more 
liable to inhale them. This mode of propagation has been taken 
to be the principal one in pulmonary tuberculosis. To such an 
extent has this belief controlled the teachings of medical men 
that the rules and regulations of health departments concerned 
themselves with this mode of transmission only. Experiments, 
however, appear to prove that the air currents usually found in 
a room are not sufficient to detach dry bacilli fastened with 
their surrounding sputum to the walls or floors. It is only 
strong currents, such as are caused by sweeping, beating, brush- 
ing, perhaps even by violent slamming of doors, that will float 
them. Under these latter circumstances it is certainly possible 
that dry bacilli may be detached in this way and infect those 
present. But experiments on animals have not yet proven that 
they could be infected by inhalations thus conducted; and it is 
quite possible that boards of health will have to alter or rescind, 
or rather extend, both their opinions and the practical rules 
built on that foundation. 

For but lately Fliigge (Zeitsch. f. Hyg. u. Inf. Krarikfi., vol. 
xxv., 1897) published a long series of experiments and observa- 
tions which appear to be able to stand accurate tests. Crying, 
sneezing, coughing, even talking, detach sputum in more or less 
invisible quantities. Everybody's experience yields such in- 
stances, palpable ones, in the sick and well. Such moist par- 
ticles, mostly infinitely small, were proven to remain in the air of 
a room five hours. Indeed, an air current of from one to four 
millimetres in a second (= twelve to fifty feet an hour) sufficed 
to float them for that length of time. In this manner the con- 
tagiousness of pulmonary tuberculosis is even more pronounced 
than by assuming the dry sputum to be the only means of con- 
veying the disease, and the direct transmission from husband to 



INFECTIOUS DISEASES. 175 

wife or children, from the woman in childbed to her newly- 
born, or between patients in a hospital ward or sanitarium 
becomes almost a matter of course; and the medical and hu- 
manitarian devices planned on hitherto imperfect knowledge 
require a far-reaching revision. 

It is evident, for instance, that the newly-born cannot be safe 
with its consumptive mother; and just as probable that a 
"sanitarium," a ward, a hospital filled with tuberculous pa- 
tients, is a hotbed of mutual infection. 

A consumptive mother must not nurse her infant because of 
the danger of immediate contact. Her milk may be, though it 
rarely is, infected like the milk of tubercular cows, even though 
their udders may not be diseased. Two cows, at least, out of a 
hundred are tubercular. Thus the least that can be done is to 
boil the milk intended for the nourishment of the infant. By 
thus obeying the rule I have enjoined these forty years, the 
milk can be made more innocuous than is possible even for 
butter* or cheese obtained from such cows. These rules ought 
to be strictly obeyed, though there be exceptions to the uni- 
versal experience. An instance of such exceptions is mentioned 
by Biedert, than whom there is no more reliable observer. He 
reports the cases of children who were fed a long time on the 
milk of tubercular cows without being attacked themselves. 
The meat of tubercular cattle is not infected (for bacilli are not 
found in muscles) and therefore not so dangerous as possibly 
its milk. But, after all, the presence of tubercular cattle in a 
community is more than simply objectionable. Its dangers 
exist, though they may have been exaggerated. That is why 
Koch's tuberculin, which failed as a cure, has proved a preven- 



* Butter does not seem to be very dangerous. For neither Schuchardt 
nor Rabinowitsch (Koch's Institute) found tubercle bacilli in eighty 
samples of butter taken from different stores and markets. Twenty- 
three of them caused, in guinea-pigs, alterations resembling, but not 
exactly like, tuberculosis (Deutsch. med. Wocli., August 5, 1897). 



176 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tive, inasmuch as it reveals the presence of tuberculosis by the 
elevation of temperature following its subcutaneous injection. 

Among the causes of consumption monotony of food has 
been enumerated by many. It is evident that it cannot account 
for much in the cases of infants or children, whose habits are 
plainer and digestive functions more adapted to simpler and 
more uniform articles of diet. Most of these, while in health, 
are satisfied with milk, cereals, and but little meat. Sweet 
cream may be added to the milk, but more than a few ounces 
are not digested through the course of a day. Cod-liver oil acts 
not only through its fat. During the afebrile condition and 
chronic emaciation, over-alimentation, introduced by Debove, 
may be tried to advantage, while the insufficiency of gastric 
digestion may be stimulated by the administration of artificial 
gastric juice (pepsin with muriatic acid) and mild stomachics 
(gentian, nux, diluted alcoholic beverages). Where exercise 
cannot be procured to a sufficient extent, or is contraindicated 
by the necessity of enforcing temporary, but absolute, rest, mas- 
sage, according to S. Weir Mitchell's plan, will take its place. 
During fever, over-alimentation is to be stopped; it deranges 
digestion and increases bodily heat. Alcoholic stimulants will 
at that time often take its place to advantage. While they do 
not act well in certain over-irritable natures, with over-sensitive 
hearts, and in haemoptysis, they are good stimuli for the general 
system, diminish perspiration, and act favorably in diarrhoea. 

In the treatment of tuberculosis no single factor is beneficial 
by itself. The quality of the air alone will not cure the sick 
any more than a certain mixture of salts and water in a mineral 
spring, or some known chemical relation of albuminoids and 
carbohydrates in an article of food. Insufficient clothing and 
bedding, unheated rooms, draughty halls, indigestible food, 
strong coffees and teas, hot cakes and cold drinks, late hours, 
lively hops, brass instruments and pianos disturbing midnight 
rest, kill as many, in proportion, in Colorado, Florida, Southern 
France, and Italy, as in New York. Unfortunately, we know 



INFECTIOUS DISEASES. 177 

too well that our patients believe they have done enough for 
their physician (or themselves?) when they have followed his 
advice to change climate. In this respect, too, it is true that 
those who speed over the sea are changing their sky, but not 
their spirit.* It should never be forgotten that the change of 
climate is mostly a negative remedy, and cannot be expected 
to offer more than the possibility of favorable external circum- 
stances. 

Moist air is a better conductor of warmth than dry air. Thus 
loss of temperature is more rapid in moist air than in dry air. 
Dry air, therefore, may be very much cooler, and is still better 
tolerated in spite of its lower temperature, and affords more 
protection. Haemoptysis appears to be a frequent occurrence 
at the times and seasons of increasing atmospheric moisture 
(spring). According to Rohden's researches a rapid increase 
of the percentage of water in the blood is frequently sufficient 
to produce a hemorrhage. Thus the drinking of large quan- 
tities of water ought to be avoided, and no residence be selected 
for a patient subject to haemoptysis where the atmosphere is 
very moist. Dry altitudes such as those of New Mexico have 
given me good results in pulmonary hemorrhage. At all 
events, no place should be selected where the percentages of 
moisture in the air are liable to change rapidly. The uni- 
formity of an insular climate is, therefore, not so dangerous to 
those who have bled from their lungs. Still, dry air and a 
higher scale of the barometer are preferable. 

The diversity of opinions in reference to the climato-thera- 
peutics of phthisis resulted from the circumstance that the in- 
dications were not distinctly understood. Neither cold nor 
warm, neither dry nor moist, air by itself is a remedy. Warm 
air does not cure, but it enables the patient to remain out of 
doors. The temperature should be uniform, sudden currents of 
air avoided, and the atmosphere free of microphytes. At an 

* "Coelum non animam mutant qui trans mare currant." 
12 



178 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

altitude of sixteen hundred feet their number is greatly re- 
duced (Miquel), there are but few at a height of two thousand 
six hundred feet (Freudenreich), very few at six thousand, 
absolutely none at twelve thousand feet, provided the parts are 
not, or but little, inhabited. Over-population of elevated 
villages and cities diminishes or destroys their immunity. In 
the factories of the Jura Mountains, with a great working 
population, at an altitude of three thousand five hundred feet, 
tuberculosis is frequent. 

Protection against sudden gushes of wind and rapid changes 
of temperature is an absolute necessity. The elevated valleys 
or rather recesses of mountains (Colorado) deserve their repu- 
tation in pulmonary diseases. Davos is dusty, windy, and ex- 
posed to frequent changes of temperature during the summer, 
and must not be advised for that season. Woods are warmer 
in winter, cooler in the summer; so is the ocean. Both, there- 
fore, deserve their reputation in the chronic ailments of the 
respiratory organs. 

Not the thinness of the atmosphere, but its purity, is the 
requisite, and a high percentage of ozone. The latter is de- 
veloped under the influence of intense light, the presence of 
luxuriant vegetable growth, particularly of evergreen trees 
(Terebinthinacege), and the evaporation of large sheets of 
water. Thus ozone is found on moderate or high altitudes, in 
needle-wood forests, and near or on the ocean. 

In the general hygienic treatment of tuberculosis the skin 
requires particular attention. Sudden changes of temperature, 
which strike the surface suddenly and work their effects on 
internal organs by reflex, — "colds," — in spite of the modern 
superciliousness of some who deny any pathological change 
unless by the exclusive work of bacteria, will always hold their 
places in nosology. The skin must be both protected and 
hardened. Wool, or wool and cotton, must be worn near the 
skin, the feet particularly kept warm, no wet or moist feet per^ 
mitted, undergarments changed according to season and the 



INFECTIOUS DISEASES. 1<"9 

alternating temperatures of 'days or weeks, and every night and 
morning. It is of the greatest importance to impress upon the 
minds of the very poorest that they must not wear during the 
day what they have slept in. Still, while protection is to be 
procured anxiously, vigor and strength is to be obtained by 
accustoming the surface to cold water. The daily morning 
wash may be warm in the beginning, and become gradually 
cooler; alcohol may be added to the water in the beginning 
(alcohol alone is unpleasant by its withdrawing water from the 
tissues), or salt. The temperature of the water being gradually 
diminished, the same treatment can be continued during the 
winter, with a pleasant sensation of vigor. The subsequent 
friction with coarse bathing towels sends a glow over the sur- 
face and through the whole body; it is desirable that, as much 
as possible, the patient perform it himself. The easiest way 
to start the habit is by washing, a short sponge- or shower-bath 
will take its place soon, and a cold plunge will be borne, even 
by the weak, afterwards. 

It has become fashionable with many to feign a contempt 
for internal medicines in the treatment of tuberculosis, pul- 
monary and otherwise. I am glad I cannot share their 
opinions. Thus, for instance, I look upon arsenic as a power- 
ful remedy in phthisis. It was eulogized as early as 1867 by 
Isnard, in a monograph, for its effect both in malaria and con- 
sumption, in both of which he explained its usefulness through 
its operation upon the nervous system. He claimed that sup- 
puration, debility, emaciation, vomiting, diarrhoea, and consti- 
pation would improve or disappear under its administration. 
The doses of arsenous acid used by him in the cases of adults 
amounted to from one to five centigrammes (one-sixth to five- 
sixths of a grain) daily. 

Arsenic is certainly a powerful remedy. It is known to act 
as a poison and a strong caustic. It prevents putrefaction, 
though as an antiseptic it ranks even below salicylic acid. It 
acts favorably in malaria, chronic skin-diseases, and maladies of 



180 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

the nervous system, and has considerable, and sometimes un- 
expected, effects in the treatment of lymphosarcoma and sar- 
coma. It is also said to improve sexual desire and power, and 
in animals physical courage. Thus there is a variety of effects 
the intrinsic nature of which may be found, uniformly, in the 
action of the drug on the function and structure of the cells, 
which, though varying in different organs, have the same 
nutritive processes. Arsenic has a stimulating effect on cell- 
growth. In small and frequent doses it stimulates the devel- 
opment of connective tissue in the stomach, in the bone and 
periosteum, everywhere; in large doses, by over-irritation, it 
leads to granular degeneration. Like phosphorus, arsenic 
builds in small doses, destroys in large ones. By fortifying 
the cellular and all tissues, both fibres and cells, it enables them 
to resist the attack of invasions, both chemical and parasitic, 
or to encyst or eliminate such enemies as have penetrated them 
already. Thus it finds its principal indication in the peculiar 
fragility of the blood-vessel walls resulting in pulmonary 
hemorrhage. 

The doses should be small. A child a few years old may 
take two drops of Fowler's solution daily, or a fiftieth or 
fortieth of a grain of arsenous acid for weeks or months in suc- 
cession. This amount may be divided in three doses, and ad- 
ministered after meals; the solution should be largely diluted. 
There is no objection to combining it, according to necessity, 
with stimulants, roborants, or narcotics, and to giving it for 
an indefinite period, unless the well-known symptoms of an 
overdose — gastric and intestinal irritation and local oedema — 
make their appearance. But they seldom will, particularly 
when small doses of opiates are judiciously added to them. In 
almost every case, perhaps in every one, it is desirable to ad- 
minister it in conjunction with digitalis. 

In the vertebrate animal, digitalis increases the energy of 
the heart-muscle and its contraction; thereby it increases 
arterial pressure and diminishes the frequency of the pulse. 



INFECTIOUS DISEASES. 181 

By increasing arterial pressure it favors the secretion of the 
kidneys, improves the pulmonary circulation, empties the veins, 
thereby accelerates the flow of lymph and of the tissue fluids, 
and exerts a powerful influence on the metamorphosis of organic 
material, — that is, general nutrition. Besides, what it does for 
the general circulation and nutrition it also accomplishes for 
the heart-muscle itself. The blood-vessels and lymph circula- 
tion of the latter are benefited equally with the rest. Thus 
digitalis, while being called a cardiac stimulant, contributes 
largely to the permanent nutrition and development of the 
heart. This effect is not only of vital importance for the 
economy of the system on general principles, but an urgent 
necessity in view of the fact that there appears to be a relative 
undersize of the heart, either congenital or acquired, in cases 
of pulmonary tuberculosis; and there is certainly such a pre- 
dominance of the size of the pulmonary artery in the young, 
particularly over the aorta, that the normal succulence of the 
lung becomes pathological quite readily when the insufficiency 
of the heart-muscle tends to lower arterial pressure within the 
distributions of the pulmonary artery. The selection of the 
preparation to be administered is not always an indifferent 
matter. The infusion and the tincture are not always well 
tolerated by the stomach; digitalin, not being a soluble alkaloid 
but a glucoside, is not always reliable in its effects, and not of 
equal consistency and strength; a good fluid extract, or the ex- 
tract, are borne well and may be taken a long time. A child a 
few years old may take about two minims of the former daily, 
more or less, for weeks and months, or its equivalent in the 
shape of the extract (two-thirds of a grain daily); the latter 
can easily be given in pills, to be taken in bread, or jelly, and 
combined with any medicines indicated for special purposes, 
such as narcotics, or nux, or arsenic, or iron; the latter to be 
excluded in all feverish cases, or in all cases while there is 
fever. As long as there is no urgent necessity for a speedy 
effect, digitalis will suffice by itself; as a rule, it does not 



182 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

operate immediately in those small doses. The addition of 
strophanthus, or sparteine, or caffeine, all of which are speedily 
absorbed and eliminated, and exhibit their effects rapidly and 
without the danger or inconvenience of accumulation, will 
prove advantageous in many cases. 

Creosote was introduced into practice, both for inhalation 
and internal administration, since 1877. No direct influence 
on bacilli should be looked for. What it can do is to better the 
condition of the patient. It will often improve appetite, com- 
bat putrefaction, thereby facilitate assimilation, and (some- 
times) relieve diarrhoea. The doses vary. Almost incredible 
doses have been given (ten to fifteen cubic centimetres = two 
to four drachms daily and more to adults). Probably from two 
to ten drops daily is a dose for children, which, according to 
their ages, may be administered for a long time. The car- 
bonate of creosote, almost tasteless, and easily borne, is a proper 
substitute in as many grains. Neither ought to be persisted in 
when the appetite does not improve within a reasonable time, 
nor during a pulmonary hemorrhage, nor when the urine which 
requires frequent examination, contains, or is beginning to con- 
tain, albumin. 

These last seven years I replaced creosote by guaiacol, 
recommended by Schtiller, Sahli, and others, which forms 
nearly sixty per cent, of the very best creosote in the market. 
A child will readily take from six to fifteen drops daily (accord- 
ing to age) in from three to four doses. It is best taken after 
meals, in sugar-water, in milk, or in cod-liver oil. There are 
but few who object to it. Those who do may take one of its 
salts, the benzoate (benzosol), salicylate, cinnamylate, or car- 
bonate. Of these I have mostly employed the last, also the 
first. They are (almost) tasteless and readily taken, in doses 
of as many (or more) grains as the fluid guaiacol in drops. In 
guaiacol I have been less disappointed than in any other in- 
ternal remedy administered in pulmonary tuberculosis, cod- 
liver oil not excepted. It is a good stomachic, appetite and 



INFECTIOUS DISEASES. 183 

digestion improve under its use, the cough gradually becomes 
looser, less purulent, the rales more mucous, and the body- 
weight is apt to increase. While creosote is not well tolerated 
in the stage of cavities and hectic fever, guaiacol is not only 
borne, but appears to exert its beneficial influence even in that 
condition. There are but few patients who do not derive some 
benefit from its internal use. Externally it has been recom- 
mended to subdue hectic fevers, for that purpose the chest and 
abdomen are painted with the pure guaiacol several times daily. 
It has the advantage over creosote of not being contraindicated 
either in hemorrhage or in renal complications.* 

I do not fear lest it be replaced by ichthyol (sulpho-ichthyolate 
of ammonium), which has been eulogized by Cohn, Scarpa, Le 
Tanneur, II. Fraenkel, and others. Adults (children in propor- 
tion) are expected to take 0.25 = four grains in a capsule before 
every meal, or twenty to forty drops four times a day of a solu- 
tion in equal parts of distilled water. In spite of the admix- 
ture of aromatic oil it has a bad taste and will be administered 
with difficulty only. 

After the failure of Koch's tuberculin several antitoxins and 
serums made their appearance. The tuberculocidin of Klebs 
and the serum of ITaragliano (which is said to contain no anti- 
toxin) have not conquered the universal good opinion of the 
profession any more than the cantharidin recommended by 
Liebreich. Koch's new tuberculin is introduced as containing 
the insoluble parts of the bacilli in finest mechanical disin- 
tegration, while the old claimed to be a glycerin extract of the 
bacilli. What it will do remains to be seen. A patient (adult) 
in Bellevue to whom I gave increasing doses, beginning with 
the minute doses recommended (one-fifth of a milligramme of 
the fluid) and rising to three minims, showed no reaction what- 
soever, though the autopsy proved the presence of extensive 



* See my paper in International Medical Magazine. November, 1S92, 
and Transactions of the Climatological Association, 1892. 



184 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tuberculosis. Nor are the exaggerated promises held out for 
the old tuberculin repeated in the new. This is said by Koch 
to exert its influence in the very beginning of the morbid pro- 
cess in the lungs, when there is no complication at all with 
streptococci or septicaemia, and when the temperature of the 
body does not exceed 38° C. (100.4° F.). It is readily seen that 
under such circumstances there will be but few cases of pul- 
monary tuberculosis in children in which, because of the ex- 
treme difficulty of the diagnosis at that age, and in that stage, 
the remedy should be administered with any show of justifica- 
tion. What the tuberculin promised* by Behring will do for 
us remains to be seen. 

Other remedies have been used in great numbers. Specifics 
have been recommended, and symptomatic treatment was re- 
sorted to. The success of the latter depends on the judgment 
of the individual practitioner. No text-book or essay can 
teach more than general principles and their adaptation to the 
average case, and the measures to be taken in a number of 
exceptional occurrences. The indications for the use of nar- 
cotics, stimulants, expectorants, and febrifuges will change ac- 
cording to the cases and their various phases. In every case 
the necessity may arise for antipyrin, antifebrin, phenacetin, 
salicylate of sodium, or quinine. It may be necessary to decide 
the question whether the administration is to be made through 
the mouth, rectum, or subcutaneous tissue, or how their effects 
are to be corrected or combined. I have often found that a 
hectic fever would not be influenced by quinine, or by anti- 
pyrin, or salicylate of sodium. But the combination of the first 
with one of the latter would frequently have a happy effect. 

The change in our pathological views, or rather the addition 
of a new factor to our etiological knowledge, has directed our 
attention to the antisepsis of the respiratory organs. To de- 



* Fifteenth International Medical Congress, Berlin, session of June 
10, 1897. 



INFECTIOUS DISEASES. 185 

stroy bacteria is not necessary in order to make them relatively 
harmless. It is impossible to kill the bacillus without killing 
the normal cell, but very mild antiseptics suffice to stop the 
efficiency and proliferation of the parasite. Thus we can hope 
that the future will teach us how to reach the destructive pro- 
cess in the lungs. For the present, however, neither the inhala- 
tion of hot air or of hydrochloric acid, nor the rectal injections 
of sulphide of hydrogen have done any good. Turpentine in- 
halations are frequently beneficial by loosening, in some cases 
diminishing, expectoration from suppurating surfaces; as they 
haye the effect, mixed or not with eucalyptol or other disinfec- 
tants, of relieving the fcetor of pulmonary gangrene. The in- 
halations of compressed air will prove advantageous in chronic 
processes where the object is to expand the contracted lung 
tissue. Inhalations of ozone may render better services in 
future than A. Caille acknowledged in 1892 (Arch, of Ped., 
August, 1892). Late personal communications exj^ress them- 
selves very hopefully. (See p. 81.) 

Operative procedures are less indicated in pulmonary tuber- 
culosis of children than in that of advanced age. The opening 
of a superficial large and copiously secreting abscess is a rare 
indication, for the latter seldom occurs except in the semi- 
adolescent; and if it does, the prognosis is anyway absolutely 
fatal. Besides, the dissemination of the tubercular process is 
so general in the lungs of the young that not more than a 
slight temporary improvement can be expected of an operation. 

Among the localizations of tuberculosis in children that in 
the larynx is not frequent, but it is met with. According to 
Heinze, laryngeal tuberculosis is not produced by contact, but 
through the medium of the blood. But the expectorated 
masses are undoubtedly a frequent cause of the local infection. 
Besides nodulated inflammatory swellings in the mucous mem- 
brane, submucous tissue and glands, sometimes even between 
the muscles, there are small granulations and ulcerations on 
the cords, with universal catarrh, oedema, and phlegmonous 



186 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

destruction. The symptoms are those of catarrh and ulcera- 
tion, and depend on the locality and severity of the lesion. In 
some cases the diagnosis of pulmonary tuberculosis could not 
be made in" the beginning, and that of the local affection was 
based on the duration of the ailment, the persistence of the 
fever, and steady emaciation. At first the laryngoscopic exam- 
ination revealed catarrh only, and only later ulceration and 
infiltration. The local treatment is that of the catarrh, — 
inhalation of warm vapors, steam, turpentine, carbolic acid, 
muriate of ammonia; poultices around the neck; opiates at 
bedtime. The spray with lactic acid and the application of 
iodoform have served me less well than a daily spray of a solu- 
tion of one part of nitrate of silver in two to five hundred 
parts of distilled water. Stronger solutions are rather harmful. 
The pain produced by ulcerations located on the epiglottis and 
arytenoid cartilages is somewhat relieved by the application 
(brush or spray) of bromide of potassium, morphine, or cocaine, 
or of an appropriate mixture of two or three of them. 

The air around patients suffering from laryngeal phthisis 
may be moist; but it is a mistake to believe that it must be 
warm. Cold air is warmed before it enters the larynx and 
lungs, provided it enters the respiratory tract through the 
nares. Only when it is admitted through the mouth it remains 
somewhat cool when reaching the larynx. Thus the nares must 
be kept as normal as possible, and competent, no matter with 
what difficulties; nor will open windows interfere with the 
comfort of the patient, provided that draught is avoided. That 
can be easily accomplished by screens or otherwise. 

Ulcerations of the tongue and pharynx are painful sometimes 
to such an extent as to require frequent attention. A well- 
directed spray, as mentioned before, of one part of nitrate of 
silver in two hundred of distilled water (glass to be of neutral, 
blue, or black color), administered once a day, will be found 
serviceable in average cases. Some are so bad as to interfere 
seriously with deglutition. I have been obliged to use a co- 



INFECTIOUS DISEASES. 187 

caine spray before every meal, or a drop of Magendie's solution 
on the tongue. For the purposes both of cure and of preven- 
tion the nose and nasopharynx should be irrigated, copiously 
and frequently, with a warm salt solution (6 : 1000). 

Tubercular ulcerations of the intestines may descend to the 
rectum; in that case the local symptoms, and mainly the te- 
nesmus, may be alleviated by warm injections containing gum 
acacia or bismuth, with or without opiates. Food and drink 
must be warm; bismuth may be given in doses of from two 
to ten grains every hour or two, so as to form a protection to 
the sore intestine. Tannin I have not seen to do much good. 
Naphthalin sweeps the whole length of the tract and acts 
favorably as a disinfectant. I have seen almost immediate im- 
provement after its use. From four to ten grains may be given 
daily (2-6 decigrammes). Now and then the stomach rebels 
against it; in that case, resorcin, in doses of from one-fourth 
to one grain (15-60 milligrammes), in a powder or in a solu- 
tion, may be given for the purpose of disinfection from three 
to eight times daily. Though it be very soluble, it certainly is 
effective to a certain extent. All of them may be combined 
with bismuth, or lead, or opium. Hydrargyrum bichloride can- 
not be relied upon for any effect in the lowest parts of the in- 
testinal tract because of its great solubility, the necessity of 
great dilution, and its ready absorbabilit} 7 . Salol in several 
daily doses of from one to five decigrammes (grs. l-J-8) is pala- 
table and effective. 

Fistula in ano is a rare occurrence in children under all cir- 
cumstances. I remember but two cases in tuberculous girls of 
about ten years. No matter whether it is an accidental com- 
plication, or the bacilli are conveyed to the parts through the 
circulation, or the fistula, is the result of the presence, in the 
fasces, of bacilli and of their action on defective epithelium, 
practice has changed entirely during the last decade. The 
axiom that fistula in a consumptive patient must not be inter- 
fered with has given way to a more rational theory and sounder 



188 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

practice. The sooner they are operated upon and treated the 
better. 

Pulmonary hemorrhages are not of so frequent an occurrence 
as in adults, but I have observed them in children of from 
three to eight years. A single instance of hemoptysis in a 
girl of eleven years proved fatal by suffocation. The applica- 
tion of a lump of ice or an ice-bag over the locality of the 
hemorrhage acts favorably, either through the direct influence 
of the cold temperature or the reflex contraction of the bleed- 
ing vessels. The subcutaneous injections of the fluid extract 
of ergot, or ergotin in glycerin and water, are very apt to give 
rise to induration or abscesses; thus it will be left to the practi- 
tioner to decide in an individual case whether that risk may be 
taken. Sclerotinic acid has been recommended for the same 
purpose. A syringeful has been injected hourly of a solution 
of one part in five of water. It is claimed that no local injury 
is done by it, but it is painful, and has been corrected by the ad- 
dition of morphine. The latter may be given internally also for 
the purpose of relieving the patient's symptoms, both objective 
and subjective. If it cannot be swallowed well, the proper 
quantity of Magendie's solution, not diluted in water, is readily 
absorbed through the mucous membrane of the mouth or 
throat. The internal administration of ergot may be supported 
by that of mineral acids and digitalis. Of the latter, a single 
dose of from two to five grains (1-3 decigrammes), or its equiv- 
alent, acts well. The dilute sulphuric acid is both efficient and 
palatable; ten or fifteen drops in a tumbler of (sweetened) 
water will be readily taken to advantage. Acetate of lead, in 
doses of one-sixth to one-half of a grain, every hour or two., 
according to age and the severity of the case, is preferable to 
tannin; it can be given with morphine or digitalis, or both. The 
patient requires absolute rest and encouragement, and must be 
induced to make long, forcible inhalations, and told to sup- 
press the cough as much as possible. To relieve it opiates may 
be required. For the purpose of stopping hemorrhages the in- 



INFECTIOUS DISEASES. 189 

halation of the sesquichloride of iron (1-100) has been recom- 
mended. As it was not expected to enter the bronchial tubes, 
its effect was presumed to be by reflex action. I have tried it 
a number of times, like many others, but cannot recommend 
it. Ligature of the extremities tight enough to constrict the 
veins, but not the arteries, is quite effective sometimes, but 
should not be continued longer than half an hour at a time. 

Night-sweats are not uncommon in the tubercular phthisis 
of children of from five to twelve years of age. They are 
favorably influenced by the same remedies which are apt to 
relieve the adult; such are the sponging with vinegar and 
water, or alum in vinegar and water. A powder of salicylic 
acid three parts, oxide of zinc ten, and amylum ninety, or sali- 
cylic acid three, amylum ten to twenty, and talcum eighty to 
ninety, dusted over the suffering surface, is quite beneficial 
and soothing. For internal administration the dilute sulphuric 
acid, ten or fifteen drops in a tumblerful of water, is found en- 
joyable by a great many. A single dose of atropias sulphas 
one-half or one-quarter of a milligramme (one one-hundred-and- 
twentieth to one two-hundred-and-fiftieth grain) at bedtime, or 
agaric acid (4-10 milligrammes), duboisine (-J or 1 milli- 
gramme), or camphoric acid in doses of from five to ten centi- 
grammes will bring relief. Where there is an indication for 
opium, it may be combined with any of them. When the diges- 
tion is good, a fair dose of quinine (three to six grains), with 
or without extr. ergot, (the same dose), or extr. ergot, fluid, 
(one scruple to half a drachm), deserves a trial when for some 
reason or other the above remedies are discarded. 

2. Syphilis. 
The nutrition of an infant suffering from hereditary syphilis 
is attended with great difficulties. Many of the mothers who 
contracted syphilis either before conception or during gesta- 
tion are anaemic in addition to their constitutional ailment; 
thus their milk is certain to be incompetent. The former class 



190 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

is very numerous, although women syphilitic before conception 
are apt to miscarry and have no living children. The latter 
class (those who contracted syphilis during their pregnancy) 
is not quite so large, fortunately; but still the question will 
come up now and then whether the baby of a woman who ac- 
quired syphilis in the course of her pregnancy should be nursed 
by her or not. The theoretical answer to this question has been 
this, that the baby may be permitted to nurse if it have been 
infected already, but must not be put to the breast if still 
healthy. That answer is no answer; for in most cases of such 
acquired syphilis, and even in the majority of hereditary syphi- 
lis (derived from a father syphilitic before conception), the 
first symptoms of the disease in the infant are visible after 
some, or many, weeks only. Thus, nobody knows whether 
the newly-born is infected or not. If such a baby be puny, 
feeble, and in poor general health, nobody would have the 
courage to deprive it of its mother's milk. Artificial feed- 
ing, as frequently carried on, would be a death-warrant. Thus, 
such a baby ought to be nursed by its mother, and, if excep- 
tions be permissible in favor of the puny, and the puny be ex- 
pected to thrive on its mother's milk, the vigorous baby's 
chance will be the better. Therefore I certainly advocate the 
baby's nursing at the breast of the mother who acquired syphi- 
lis during pregnancy, no matter whether the symptoms of the 
disease be visible in the baby or not. Meanwhile, both mother 
and baby must be subjected to a thorough and prolonged anti- 
syphilitic treatment. 

The same baby must not be put to the breast of a healthy 
wet-nurse, no matter whether symptoms have made their ap- 
pearance in the baby or not; or whether the baby has been 
subjected to an antisyphilitic treatment or not. For the nurse 
must not be exposed under any circumstances, without at least 
having been made fully aware of the risk she is running. 

The mother of a baby infected with hereditary syphilis is 
herself either syphilitic or not. If the latter, she is immune as 



INFECTIOUS DISEASES. 191 

regards her infant, — that is, she will not be infected by her 
nursing syphilitic infant. In both cases she must and may 
nurse. For if syphilitic herself, she will not render the case of 
her infant more serious; if not, she cannot transmit a disease 
she has not herself. In neither case can she be infected by the 
diseased infant. In either case, both mother and child must be 
treated. 

In no case must a baby, either hereditarily syphilitic or sus- 
pected of hereditary syphilis, be put to the breast of a healthy 
wet-nurse. Syphilis contracted through the infection of the 
nipple is liable to be as destructive as that which attacks physi- 
cians through their fingers. Such a wet-nurse must be forbid- 
den to nurse altogether, or permitted only with a full knowl- 
edge of the circumstances, and directed, if she accept a place 
after all, to nurse through an artificial nipple. Meanwhile, the 
syphilitic or suspected baby must undergo an antisyphilitic 
treatment. If only suspected, but for good reasons, the treat- 
ment should not be postponed until positive symptoms may 
have made their appearance. For mercurial treatment is a less 
grave interference in the young than in the old, and nothing 
can be more reprehensible than the opportunity given to con- 
stitutional syphilis to obtain full sway. 

From what has been said of the many contraindications to 
the infant being brought up at the breast, it follows that arti- 
ficial feeding must often be resorted to. This circumstance 
impairs the prognosis considerably, and claims the best knowl- 
edge and soundest judgment of the well-informed practitioner. 
Improved methods of artificial feeding, however, improve the 
prognosis. 

The prevention of hereditary syphilis is based in part on that 
of syphilis in general. Public hygiene is not benefited, as they 
try to do in New York, under the guidance of a combination of 
ignorance and hypocrisy, by disseminating venereal diseases 
throughout the whole city; but by wise superintendence and 
control of the "social evil." A syphilitic person must not 



192 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

marry. When a man has contracted syphilis he ought to be 
treated methodically two years, and before he marries three 
years ought to elapse after the last symptoms of syphilis were 
noticed. During pregnancy in suspected wedlock, both man 
and woman ought to be treated. 

Preventive treatment is required both on the paternal and 
maternal side. Syphilitic endometritis leads mostly to mis- 
carriage; when the embryo and foetus survives, the newly-born 
exhibits syphilis at once. Women infected during pregnancy 
may, or may not, infect the offspring, according to the time of 
their own primary and secondary symptoms. It is impossible 
to be sure. In all of these cases a thorough and protracted 
antisyphilitic treatment is required. For practical reasons, for 
women with habitual abortion, where the diagnosis cannot be 
positively made, I advise and practise mercurial treatment. 
Most cases of hereditary syphilis, however, are derived from the 
father. It is he who has to undergo a strict and effective treat- 
ment for the purpose of extinguishing the calamitous malady. 

The medicinal treatment of hereditary syphilis requires the 
several preparations of mercury, in many cases iodides also. 
Mercurial preparations are well borne by infants and children. 
Stomatitis and gingivitis are very exceptional occurrences. 
The indications, modes of administration, and doses of the 
remedies depend, to a great extent, on the locality or organ 
affected, whether skin, mucous membrane, subcutaneous tissue, 
lymphatic glands, muscles, bones, the viscera of the thoracic or 
abdominal cavities, the nervous system, or the sensory organs; 
and on the time at which the first symptoms become percep- 
tible. In the majority of cases this takes place between the 
fifth and eighth weeks of life. Then the nose, lips, and anus ex- 
hibit rhagades; these fissures are apt to be quite painful; the 
skin is getting covered with roseola, the palm of the hand and 
sole of the foot with efflorescences; the complexion becomes 
sallow without being uniformly so at all times, for indeed 
changes and a certain degree of intermission are observed. 



INFECTIOUS DISEASES. 193 

After a while maculous, squamous, and papulous eruptions 
make their appearance, pustules and vesicles spring up and 
terminate in ulcerations, gummata appear in the skin. This 
form permits of a fair prognosis, particularly in the cases of 
infants reared at the breast. The treatment can be carried out 
slowly and systematically. 

It consists in the internal administration of calomel; doses 
of from one-twentieth to one-sixth of a grain can safely be 
given three times a day, for months in succession. If in any 
case diarrhoea were to set in, and no fault be found in the food 
administered, or in the condition of the digestive organs which 
may have been impaired by other causes, from a twentieth to a 
twelfth of a grain (3-5 milligrammes) of Dover's powder may 
be added to each dose. 

Other preparations which have been recommended, are the 
bichloride and the cyanide in doses of from a one-thousandth 
to a three-hundredth of a grain several times daily. The green 
iodide of hydrargyrum is not so well tolerated as calomel, and 
the oxidulated tannate of mercury, recommended by Lust- 
garten, does not seem to offer any advantages. As these pages> 
however, are being written for practical guidance, and not for 
the elaboration of the history of therapeutics of infant syphi- 
lis, I can but advise the use of calomel as effective and suffi- 
cient. The use of the blue ointment has been eulogized under 
the impression that the internal administration of the drug 
might lead to digestive disorders. As inunctions made in the 
usual way were found to irritate the skin (oleates are objec- 
tionable for that reason alone), it was recommended to apply 
it to a sheet of soft leather surrounding the knee, and to secure 
its slow absorption by the spontaneous movements of the 
baby's extremities. Thus the treatment is left to a great extent 
to the patient, and the actual dose cannot, to say the least, be 
determined upon or even estimated. TYiderhofer modifies in- 
unctions by applying a mercurial plaster of the size of the 
hand, which he changes once a week, to the intrascapular re- 

13 



194 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

gion, and praises his results. When the skin is badly affected, 
from one to two grammes (grs. 15-30) of the bichloride of 
mercury may be added to the daily bath of the infant. This 
external treatment also may be continued for weeks. 

A similar treatment is required in those cases in which an 
infant or child (in the latter in larger doses) has acquired syphi- 
lis in one of the many ways in which the disease can be con- 
tracted. The ritualistic sucking out of the circumcised prepuce 
has given rise to syphilis as it has produced tuberculosis; syphi- 
litic nipples of a mother or nurse, vaccination, kissing, the 
brushing of the throat with infected instruments, in older chil- 
dren sexual contact, are much too frequently causes of syphilis. 
This acquired syphilis of infancy and childhood is apt to run a 
swifter and more deleterious course than the same disease in 
most adults. Therefore it may become necessary to add to the 
above treatment such methods as have proven most effective 
and speedy in the most urgent cases of hereditary syphilis also. 

These urgent cases run a different course from those briefly 
sketched above. In many of them the diagnosis of hereditary 
syphilis can be made immediately after birth. General pem- 
phigus of the surface of the newly-born is not a symptom of 
syphilis, but localized pemphigus of the palms of the hands and 
the soles of the feet is. It is but seldom the only symptom, 
though it requires often a close observation not to overlook the 
affections of internal viscera and the bones. The latter are 
often the seat of syphilitic disintegration; in the costo-carti- 
laginous junctures Wegner studied the changes worked by 
syphilis, which resemble very much those of early rhachitis. 
Liver, spleen, pancreas, and lungs exhibit two different 
changes, either gummata or intestinal proliferations of the con- 
nective tissue. In the liver these are mainly met with along the 
blood-vessels and bile-ducts, and capable of producing jaun- 
dice, and even total and permanent obstruction of the ducts 
in the foetus or the newly-born. An early tumefaction of the 
spleen was the first prominent symptom in one of my cases. 



INFECTIOUS DISEASES. 195 

Twice I have seen both testicles the seat of syphilitic tumors 
in the newly-born. The blood-vessels suffer at an early period. 
The syphilitic arteritis, first described by Heubner, gives rise 
to congestions and hemorrhages (petechia? and purpura) on 
skin and serous membranes, in the intestines and kidneys, in 
the cranium, and in the thymus gland. And many early brain 
symptoms and sudden deaths of the newly-born are due to 
intracranial hemorrhages, oedema, and softening from the same 
causes. Nor have the sensory organs of the newly-born any 
immunity. C. S. Bull has met with iritis and choroiditis. 

These are the cases in which the systematic calomel treat- 
ment is insufficient. In them it is of the utmost importance to 
get the system immediately under the influence of mercury. 
With or without the internal treatment subcutaneous injec- 
tions of mercury must be made at once. The subcutaneous in- 
jections of calomel, which I, like many others, have tried in the 
adult, have given me, contrary to many assertions of its spon- 
sors, so much trouble in the shape of abscesses or indurations, 
that I cannot bring myself to recommend them in the newly- 
born, with its spare connective tissue. But a solution of from 
one to two grains of bichloride of hydrargyrum in an ounce of 
distilled water (1 :'240) is quite innocuous. It can be safely 
injected once or twice daily, in doses of from one-hundredth 
to one-fiftieth of a grain (1-2 milligrammes). That treatment 
I have followed in many an urgent case more than two dozen 
years, and can safely recommend it. No reliance should be 
placed on mercury given to the mother or nurse, for its elimi- 
nation through breast-milk is an uncertain process and an un- 
known quantity. 

When the bones and glands suffer at an early period, the 
mercurial treatment ought to be combined with the adminis- 
tration of the iodides. Potassium iodide may be given to the 
infant in doses of from five to twenty grains (3-6 decigrammes) 
daily. Under all circumstances, the treatment has to be per- 
sisted in many months after the disappearance of the very last 



196 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

symptoms. In spite of that the constitutional disorder may 
break out again, either in its original form, or as an osteitis 
only, leading either to caries or to sclerosis; or as a cerebral or 
spinal affection. That is why, when the symptoms have dis- 
appeared, recovery should not be taken for granted. After it 
seems to have been accomplished, the patient may be left alone 
for a month or two. Then the treatment ought to be resumed 
similarly to what we ought to do in the case of an adult who 
should not be considered safe until years have elapsed without 
a symptom. Syphilitic arteritis, meningeal exudation, or gum- 
matous tumor may lead to ptosis, nystagmus, facial paralysis, 
hemiplegia, hemichorea, or idiotism; to myelosclerosis or trans- 
verse myelitis. A syphilitic inflammation of the labyrinth with 
Meniere's symptoms has been observed in a girl of five years 
by Knapp, and interstitial keratitis, also retinitis, appears to 
result from syphilis quite often. A painless otitis media was 
noticed by Fournier. In all such cases the energetic treatment 
with mercury and iodides combined has to be resumed, and 
continued for an indefinite period. But it has often appeared 
to me that syphilis will do more than produce those unmistaka- 
ble symptoms. There are many cases of "scrofula," chronic 
lymphadenitis, and rhachitis which — with no other causes to 
account for them — appear to point to previous syphilis not 
completely extinguished. In a number of my own cases I have 
personal knowledge of such a history. Such cases do not only 
explain the fact that many old authors recommended mercury 
in "scrofula" and "rhachitis," but also that there are some in 
which that treatment is indispensable. But lately I had to deal 
with chronic cervical adenitis, mainly of the left side, and pul- 
monary infiltration of the left upper lobe, in a baby of two' 
years. They resisted the usual treatment for more than a year 
before the suspicion of its syphilitic nature was roused and the 
history of the disease elicited. Six weeks of a mercurial and 
iodide treatment have worked a miraculous change in the local 
and general condition. 



INFECTIOUS DISEASES. 197 



3. Intermittent Fever. 



In older children it has the same type as in adults. We 
have acute and chronic forms, the quotidian, tertian, and 
quartan types. There are the same results and anatomical 
lesions. There is the general anaemia, in infants and children 
most rapid and detrimental, the splenic tumor, the hemor- 
rhages, the amyloid degeneration. 

It is only in the newly-born infants and very young children 
that the diagnosis becomes difficult. In them the type is mostly 
quotidian. Besides, the attack may come at irregular times. 
Not infrequently is it seen in connection with catarrhal dis- 
eases, which appear to create a susceptibility to the poison. 
The chills are not easily diagnosticated. Perspiration is very 
frequently not profuse. The tumor of the spleen can be recog- 
nized by palpation at a late period only, but the temperature 
is apt to be very high. Sometimes the attack is not recognized, 
because of the first symptom being a convulsion. Masked cases 
are not uncommon; intermittent pneumonia, neuralgia, even 
paralysis have been observed. Holt observed intermittent tor- 
ticollis and bronchial asthma. Attacks of vomiting, also diar- 
rhoea have been noticed. For all these reasons the diagnosis is 
often not made. On the other hand, the diagnosis of malaria 
is made improperly in too many instances. In every doubtful 
case the blood should be examined for plasmodia. The subse- 
quent severe anaemia, as blood-cells are rapidly destroyed, is 
liable to be very obstinate. Among the sequelae glomerulo- 
nephritis is not uncommon. 

Quinine ought to be given, if the attacks come at regular 
intervals, in a single dose, three or four hours before the attack. 
That is the time when the plasmodia are small and movable. 
If they occur at irregular periods, it is better to divide up the 
total amount of quinine in three or four doses, to be given 
through the day. In the first case a dose of five grains (3 
decigrammes) will suffice for a child of three years; in the 



198 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

second case eight or ten grains (5 decigrammes) will be re- 
quired. 

It is not always easy to give quinine because of the taste. 
A solution ought not to be tried for the same reason. Ona 
part of the sulphate of quinine may be given with forty parts 
of elixir simplex, but in every case the dose must be mixed just 
before given. The neutral tannate of quinine is tasteless, and 
may be given as a powder, but for one part of the sulphate two 
and a half of the neutral tannate should be administered. The 
sulphate may be given mixed in chocolate — older children will 
take it greedily — or in coffee or syrup of coffee. When it can- 
not be given internally, rectal injections may take the place 
of the internal administration. No acid must be added to the 
solution; therefore very soluble preparations only must be 
used, for instance, the bromide, the muriate, the bisulphate, 
the carbamide; or suppositories can be given, but with less 
positive effect than that of other modes of administration. In- 
unction of quinine has been recommended a great many times. 
The ointments made as usual with animal fats have but very 
little effect. Where it would be impossible to use any other 
method, quinine might be dissolved and mixed with fat and a 
larger quantity of lanolin; but even in this case the dose which 
really penetrates the skin and enters the circulation cannot be 
determined. A subcutaneous administration of quinine be- 
comes necessary when no other can be resorted to, or when an 
immediate effect is required. The best preparation for the pur- 
pose is the carbamide, which will dissolve in from four to six 
parts of warm water, and give rise to less induration than we 
are liable to meet with when using the other salts. When re- 
covery appears to be established, it is advisable to give a weekly 
dose of the drug for some time. 

In the chronic form arsenic is the principal remedy, as in 
the cases of adults. A child of three years may commence with 
one drop of liquor potassii arsenitis (Fowler) three times a day, 
to be administered as detailed in a former chapter. The liquor 



INFECTIOUS DISEASES. 199 

sodii arsenatis of the Pharmacopoeia may take its place in those 
cases in which the stomach is very irritable; also the prepara- 
tion of the same name as introduced by Pearson, which is ten 
times milder than the officinal preparation, and must be given 
in proportionate doses. If the solutions of arsenic be not well 
tolerated, the arsenous acid may be given instead. It may be 
administered in the shape of pills in doses of one one-hundred- 
and-hftieth to one-hundredth of a grain, three times a day, or 
more, to children of three years, or it may be administered as a 
powder in combination with other medicines. It may be safely 
mixed with bismuth, for the disagreeable odor emanating from 
persons taking bismuth, which has been attributed to arsenic 
contained in the bismuth, really belongs to a minute dose of 
tellurium inseparable from some specimens of bismuth in the 
market. All these preparations of arsenic may and should be 
given for many weeks or months. Constitutional symptoms 
belonging to an overdose I have seen more frequently when 
using Fowler's solution than any of the other preparations, but, 
after all, they are rare. 

Tincture of eucalyptus has been given in acute, and particu- 
larly in chronic, cases. It renders good service now and then 
in doses of from ten to twenty-five drops, three or more times 
a day. Methylene blue is unreliable. 

As there are very obstinate cases in the adult, so there are 
in children. In them, too, the spleen may remain large and 
the attacks return indefinitely. These are the cases which try 
the endurance of the patient and the patience of the physician. 
In them I have seen excellent results from the use of ergot 
these forty years. Ergot may be given as fluid extract, and 
then a child of three years may take from a scruple to a drachm 
(4 cubic centimetres) every day for weeks in succession, or a 
corresponding quantity of the extract of ergot. — that is, from 
three to ten grains (2-6 decigrammes) every day, either in 
mixtures or, for older children, in pills. I have noticed in a 
good many cases, in which the fluid extract was not tolerated 



200 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

at all, that the extract of ergot, when given in the latter shape, 
was easily tolerated. 

Subsequent anaemia demands the syrup of iodide of iron and 
other medicinal and hygienic treatment. 

4. Typhoid Fever. 

Though occurring in the first few weeks of life, it is rare in 
the first years. Most cases are met with between the sixth and 
the twelfth year. 

Its danger may come from many causes; from previous ill 
health and anaemia, which may depend on a feeble constitution, 
hereditary syphilis, chronic ailments of the organs of digestion, 
of respiration, and of circulation; from the intensity of the 
invasion, which sometimes is manifested by a high initiating 
temperature, and early septic symptoms; from an unusually 
high temperature; from insufficient power or actual failure of 
the heart; from diarrhoea, intestinal hemorrhages, perforations, 
and local or general peritonitis; from complications such as 
meningitis and nephritis; and, finally, from consecutive dis- 
eases. 

The uncertain symptoms of the first days render the diag- 
nosis difficult. Sometimes it is made by exclusion only. If a 
characteristic curve of the typhoid fever, the tongue of infec- 
tious fevers, diarrhoea, tympanites, large spleen, roseola (appear- 
ing between the sixth and the eleventh day), and a positive diazo 
test are present, it is not doubtful. It may be difficult to detect 
a pneumonia even after days, but after a while local symptoms 
will permit a differentiation. Miliary tuberculosis may be mis- 
taken for a severe case of typhoid fever, but when it is localized 
in the cerebral meninges, the slow and irregular pulse, vomit- 
ing, constipation, and diminished action of the kidneys secure 
the diagnosis of tubercular meningitis. There are, however, 
cases in which the general symptoms do not seem to agree with 
the elevation of the temperature and other symptoms. I know 
of no other serious and protracted disease in which the patients 



INFECTIOUS DISEASES. 201 

will quite often declare themselves to be so well in spite of 
marked objective symptoms to the contrary. Widal's test, 
though not positive and mostly available in the second week 
only, is suggestive of the presence of typhoid fever. The dem- 
onstration of the bacillus, if well distinguished from bacterium 
coli commune, is proof positive. 

Preventive treatment has led to very good results. Many 
houses and towns which were the seats of endemic typhoid 
fever have been rendered immune by improving the sewerage 
and the condition of the neighborhood. For typhoid fever and 
dysentery can be traced positively to exhalations of privies and 
sewers, while with regard to other diseases we can only say that 
animal exhalations from the same sources may create a predis- 
position by impairing the general health, but are not able to 
produce specific diseases independently of other influences.* 
Where the drinking-water is suspected, it ought to be boiled. 
No raw milk should be given. The faeces of the patient must 
be disinfected, though there be no diarrhoea, by crude muriatic 
acid, or a five-per-cent. solution of carbolic acid, or by copperas. 
The sick should be isolated when they suffer from typhoid diar- 
rhoea, and the practice still prevalent in hospitals to place 
many typhoid patients in general wards should be abolished. 

Can typhoid fever be aborted? or, in other words, can its 
first stage be interrupted? An affirmative answer to this ques- 
tion has often been given, but it is difficult to prove the correct- 
ness of the diagnosis in an alleged case of typhoid fever that 
lasted a few days only. While with our present knowledge we 
cannot believe that the proliferation of the toxin floating in the 
blood may be interrupted by antifermentative treatment, it is 
certainly either justifiable or advisable to try the effect of other- 
wise not injurious anti ferment atives, such, perhaps, as creosote 
or hydrochloric acid, if it were only for their effect on the intes- 

* A. Jacobi, "The Production of Diseases by Sewer Air," Transactions 
of the Congress of American Physicians and Surgeons, 1894, and N. Y. 
Med. Journ., 1894. 



202 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tinal tract. As regards the early administration of a large dose 
of calomel, its effect is notoriously good, no matter whether 
it acts as a disinfectant directly on the toxin, or whether it 
simply relieves the intestinal tract of the toxin introduced 
and in progress of proliferation. A child of three years may 
take a dose of three or four grains (two or three decigrammes); 
a child of eight years one of seven or eight grains. While the 
purgative effect of the calomel can be obtained by simply in- 
troducing the powder into the mouth, there to be absorbed, it 
is better in this case to let it be swallowed. It can be safely 
given during all of the first week of the disease. When, as fre- 
quently, there is constipation during the course of the disease, 
calomel is no less beneficial, but then it should be given in 
smaller doses, which may be repeated. During the diarrhoea 
of the second or third week it should not be given. 

With regard to the general treatment of the typhoid fever 
of children, we are equally liable to injure either by overactivity 
or by neglect. The so-called expectant treatment has its great 
dangers in the hands of those who make it their invariable 
rule; it is safe in the hands of those only who have learned 
to treat the sick rather than the sickness. The air in the sick- 
room should be cool, the windows open. Draughts, it is true, 
should be avoided, but screens around the bed will permit the 
opening of both windows and doors. The bed-sheets must be 
smooth; four or eight safety-pins will fasten them to the cor- 
ners and sides of the mattress. At an early period the whole 
surface ought to be washed oftentimes either with water or 
with alcohol and water. The hair, when long, ought to be cut. 
The children should be allowed plenty of water. Those who 
are liable to have dry lips and tongue must be made to drink a 
small quantity of either water or dilute muriatic acid in water, 
ten minims to the tumblerful, every ten or twenty minutes. 
Fissures around the lips or in the tongue ought to be washed 
with a saturated solution of boracic acid, or, when bleeding, 
should be painted once a day with a mild solution of nitrate of 



INFECTIOUS DISEASES. 203 

silver (not more than one per cent.), the lips also with an oint- 
ment consisting of boracic acid and lanolin. 

Very much depends on the mode of feeding. Xo solid food 
must be given. Boiled milk, milk on the Eudisch plan, broths, 
farinaceous decoctions, strained. For older children, one or 
two soft-boiled eggs diluted in broth, either the whole of them 
or the white only; meat-juice, albumoses. As a general thing, 
more albuminoids than carbohydrates ought to be given. The 
food should be so arranged as to be digested in the stomach and 
small intestines, and not encumber the colon. If necessary, a 
small quantity of pepsin and muriatic acid may be given with 
it. Peptones may be given, but they must not form anything 
like the exclusive diet. I allow no solid food before ten days 
have elapsed after apyrexia set in. 

The tendency to complications with bronchitis requires fre- 
quent changes in the position of the patients. They ought to 
be turned from their backs to their sides every few hours, and 
back after a while; otherwise they ought not to be moved too 
much. Particular care ought to be taken not to raise them too 
often. Physical and mental rest is an absolute necessity. Def- 
ecation must take place in the recumbent posture. They must 
not be permitted to strain. Some warm tepid antifermentative 
injections should be made daily into the bowels (thymol 
1 : 2000). 

The danger arising from high temperatures varies in different 
patients. Their injurious influences depend, from a clinical 
point of view, on many causes, foremost among which are both 
individual susceptibility and the length of time during which 
the child is exposed to its internal heat. A high temperature 
lasting but a certain time, and alternating with either an inter- 
mission or a remission (as, for instance, intermittent or relaps- 
ing fevers), may not prove dangerous at all, and may not re- 
quire any treatment. But the frequent repetition of elevated 
temperatures, or their long duration, demand interference. 
Therefore they ought to be measured at least four times a day, 



204 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

particularly as typhoid fever is apt to yield two daily exacerba- 
tions and remissions. 

Continued high temperatures in the course of typhoid fever, 
or intense fever at the very beginning of the disease, require 
treatment. In them the frequency and quality of the pulse, 
and the functions of the nervous system, are seriously disturbed 
at an early time. Under the influence of a cold bath both tem- 
perature and heart-beats diminish, arterial pressure increases, 
and the intellect becomes clear; it has a peculiarly favorable 
influence on the infant and child. In them the surface is rela- 
tively larger than in adults, and the cooling is more rapid and 
intense. The circulation is easily disturbed, the surface tem- 
perature not readily restored afterwards. It may happen that 
the internal temperature rises while the external blood-vessels 
are contracted by cold, and the internal organs become en- 
gorged. In those cases a hot bath is more liable to restore radi- 
ation from the skin and reduce internal heat. Whenever no 
immediate reaction takes place, — mainly about the extremities, 
— after the child has been taken from the bath, this must not 
be repeated, and the feet kept thoroughly warm. In such cases 
a warm bath is infinitely milder and more useful; or where the 
temperature is high and threatening, a cold pack — as detailed 
in a former chapter — around the trunk is preferable. At the 
same time the feet must be kept warm and a stimulant given. 
Cold applications to the heart are frequently sufficient to re- 
duce the temperature. In such cases as develop sopor at an 
early period, together with high temperatures, the pouring of 
tepid or cool water over the head, or head and shoulders, is very 
beneficial. The contraindications to the use of the cold bath 
are general debility, weakness of the heart, cold extremities, a 
cold surface, complicated with high internal temperature, and 
intestinal hemorrhage. 

The medicinal agents used to reduce temperatures in typhoid 
fever are salicylate of sodium, antipyrin, antifebrin, phenacetin, 
and quinine. Kairin and thallin deserve no recommendation, 



INFECTIOUS DISEASES. 205 

for the reason that, while their effect is no better, their efficacy 
is soon exhausted, and the drug has to be repeated after very 
short intervals. All of the medicines mentioned above must 
be given carefully. To avoid a possible debilitating effect on 
the heart, a general or cardiac stimulant should be given at 
the same time. All of them may be given in small doses, and 
frequently repeated, when the remission is not marked; but as 
a rule an occasional larger dose is preferable. Antipyrin can be 
administered internally, through the rectum or, if urgently de- 
manded, subcutaneously. A child of three years may take from 
eight to twenty-five grains (one-half or one and a half 
grammes) a day, in from two to four doses, two of which have 
often to be given in close proximity (the second after an hour 
or two hours). The dose of antifebrin is but one-third or one- 
quarter of that of the former. It is, because of its more diffi- 
cult solubility, not available subcutaneously, and less so than 
antipyrin, in the rectum. Phenacetin may be given in doses 
of from one to five grains (five to thirty centigrammes), twice 
or three times a day, to a child of the same age. The adminis- 
tration of quinine follows, as a rule, the method detailed above, 
but in typhoid fever it is liable to disorder the stomach and 
intestine and produce diarrhoea or tenesmus. Its time is the 
remission, its single dose from five to seven grains (half a 
gramme or less), once a day or every other day. and its best in- 
dication the persistence of the splenic enlargement in the 
course of the third week of the disease. The combination of 
quinine with one of the other antifebriles yields good results 
quite often when one of them does not appear to be sufficient, 
in the same way that the effect of a tepid bath combined with 
an antifebrile is, now and then, quite astonishing. 

The intestinal tract is the seat of many dangers. Tympanites 
and meteorismus depend on the paralytic condition resulting 
from enteritis only, or from enteritis and peritonitis. The lat- 
ter is either local, and corresponds with the local ulcerations, or 
general. Cold applications are serviceable. Enemata of ice- 



206 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

water will sometimes do good; or of an aromatic infusion 
(chamomile, anise, fennel, catnip); sometimes of turpentine, half 
a teaspoonful or a tablespoonful mixed with the fluid (water, 
or soap and water). The introduction of a large catheter, with 
one or more additional eyes, may relieve the lowest part of the 
intestine of gas. Puncture of the inflated intestine by means 
of a small syringe ("hypodermic") is not dangerous in such 
cases where it is not required. Where it would be of service, 
however, — that is, in the very worst forms of intestinal paral- 
ysis, with intense and dangerous inflation, — it is injurious. 
For in these cases the elasticity of the intestinal wall is gone, 
and the small punctures in the intestinal wall remain open. I 
have seen faeces entering the abdominal cavity through them, 
and fatal peritonitis, of my own making. 

Diarrhoea, when moderate, need not be interfered with in 
any period of the disease. It is probable that the initial dose 
of calomel prevents it in a great many cases. When it is 
copious, such remedies as pass through the whole length of the 
intestine will render good service either by their soothing or 
disinfectant effect. Subnitrate or subcarbonate of bismuth, 
from a scruple to a drachm daily (one to four grammes), are 
valuable. Salicylate of bismuth does not always act kindly in 
the stomach. Naphthalin, half a grain to a grain (three to six 
centigrammes) every two hours, when tolerated by the stomach, 
— in most cases it is, — improves the odor of the evacuations 
and diminishes their number. In many cases I have given it, 
for its disinfectant action, from the very beginning of the fever. 
Salol, in doses of from one to three grains every two hours, 
has a similar effect. Mild doses of opium may be added, from 
half a minim to a minim of the tincture, every two or four 
hours. Eesorcin is better tolerated than either, but it does not 
pass the whole tract. Cold applications, covered with rubber 
cloth and (or) flannel must be changed every twenty or 
thirty minutes. Warm applications may take their places 
when the little patients are quite feeble and anaemic. Among 



INFECTIOUS DISEASES. 207 

the astringents, when required, I prefer acetate of lead in small 
doses of five or more milligrammes each. Both tannin (gallic 
acid is milder) and alum are liable to annoy the stomach. 

Constipation is much more frequent in our cases of typhoid 
fever in both the young and old than in the descriptions of the 
books, both European and copied. When not too persistent 
it is not objectionable; for most children have not suffered 
from constipation before the disease began, and accumulation 
of faeces is not a very prominent feature in them. When there 
is peritonitis it must not be disturbed, at any rate. In no case 
must strong purgatives be given. Castor oil in small doses may 
become necessary; half a teaspoonful or a teaspoonful, every 
few hours, may then be given, or small and repeated doses of 
calomel, from a quarter to one-half of a grain. Eectal injec- 
tions of tepid water, with, or mostly without, turpentine or 
thymol, will be all that is required in most cases. 

Perforations require the treatment best adapted to eutha- 
nasia, — viz., opium and stimulants; (mostly) cool applications 
to the abdomen, and hot ones to the feet. Maybe an occasional 
case will be saved by surgical interference. 

Hemorrhages are not so frequent, as in the typhoid fevers of 
adults, in those of the very young, because of the superficial 
character of the ulcerations. But in older children the intes- 
tinal lesions are apt to be as grave as in more advanced periods 
of life. No food should be given for some time, drink in small 
quantities only, but repeatedly. Applications of iced cloths, an 
ice-bag, or a lump of ice — to lose no time — to the right hypo- 
chondrium. They may be moderately heavy, for compression 
may have a local influence. Hot injections into the rectum 
have no styptic effect, iced ones may act through reflex. In- 
ternally, alum or lead, one-quarter or one-half grain (fifteen to 
thirty milligrammes) or more, every hour or two hours, with 
opium and digitalis. Ergotin, or fluid extract of ergot, and 
other preparations of the drug which were claimed to be in- 
nocuous, I have seen to give rise, frequently, to indurations or 



208 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

abscesses after their subcutaneous administration. Their effect 
is mostly questionable. I have seen gangrene over a large sur- 
face after their use, and pyaemia several times. In the case 
of a little girl, I had to incise about sixty metastases in the 
course of two months before she was saved from a pyaemia 
which resulted from a single hypodermic injection. The in- 
ternal administration of ergot may be tried when the condi- 
tion of the stomach permits it. Subcutaneous injections of 
sclerotinic acid (one to five) have been recommended; they are 
painful. To counteract the imminent fatal termination I have 
been compelled to perform transfusion of blood in the case 
of an adult; she recovered, but died on the fiftieth day of a 
relapse. Injections into the subcutaneous tissue of large quan- 
tities of sterilized salt water (6 : 1000) yield most surprising and 
life-saving effects in urgent cases of utter exhaustion. 

The condition of the heart cannot but influence the course 
of the disease, its complications and consecutive disorders. It 
cannot help being enfeebled by a serious and protracted disease 
such as typhoid fever; still, how far this feebleness will extend 
cannot be predicted. Besides, it depends to a great extent on 
causes not exactly connected with the infection itself. Among 
these accessory causes are original — congenital — debility and 
chronic heart-diseases previously contracted. Besides, the in- 
fection itself with its accompanying fever is apt to give rise to 
an acute myocarditis, or to granular degeneration of the heart- 
muscle. Among the symptoms of debility of the heart, which 
may easily lead to complete heart-failure, are pallor of the skin 
and of the mucous membranes, purplish and cyanotic hue, par- 
ticularly of the lips, ears, and finger-ends, mottled appearance 
of the surface depending on venous stagnation in the small 
blood-vessels, cold extremities and nose, slow or, more com- 
monly, frequent pulse, which, moreover, is arhythmic, and a 
heart-beat the sounds of which are either split or embryocar- 
diac, — that is, exhibiting equal intervals between the first and 
second sounds. In other cases the danger is indicated by the 



INFECTIOUS DISEASES. 209 

close proximity of the second sound to the first to such a degree 
that the former is scarcely audible. 

The brain symptoms belonging to heart-failure are those of 
anaemia. When beginning to treat them, we should not forget 
the possibility of an error in the diagnosis of the condition, 
which may be quite serious, because the signs of anaemia and 
hyperaemia are in many respects the same. However, the gen- 
eral indications for the treatment of heart-failure may be laid 
down in a few rules, the first of which refers to prevention. 
As heart feebleness must be expected in every protracted dis- 
ease, and failure feared in many, we ought to act, as a matter 
of prevention, exactly as the surgeon does in his operations. 
Before the times of antisepsis and asepsis there were performed 
a great many operations that would not lead to sepsis or erysip- 
elas. Indeed, these mishaps were the minority, perhaps a small 
one at that. But they did occur, and that is why no surgeon 
would at present perform any operation, either serious or trifling, 
without measures to secure asepsis. If he neglected them, he 
would justly be held responsible for any mishap in the shape 
of erysipelas or pyaemia. Now, the certainty of cardiac debility 
and the danger of heart-failure are much more threatening in 
an infectious fever than those complications of convalescence 
after an operation. Therefore in no case of typhoid fever 
ought the heart to be left alone to fight its own battle unaided, 
with the chances of being overexerted (with possible hyper- 
trophy from that cause), fatigued, or exhausted. The doses of 
cardiac stimulants cannot be stated categorically, but the prin- 
ciple must be established that it is a good rule to give moderate 
amounts of digitalis, strophanthus, convallaria, sparteine, caf- 
feine, or an alcohol beverage. The particulars have either "Been 
stated in a former chapter or must be left to the judgment of 
the practitioner. Digitalis and strophanthus may derange the 
stomach after a while; digitalis may not act quickly enough 
under certain circumstances; in such a case sulphate of spar- 
teine, which is readily dissolved, absorbed, and eliminated, in 

14 



210 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

doses of one-tenth to one-half of a grain (six to thirty milli- 
grammes) every one, two, or three hours will render good ser- 
vice. Caffeine must not be given when there is hyperemia of 
the brain. The sodio-benzoate and sodio-salicylate of caffeine 
dissolve readily in two parts of water, and are reliable aids in 
sudden attacks of heart-failure, in hypodermic administration. 
(Dose: five to twenty centigrammes.) Camphor internally, in 
doses and according to methods described before, will answer 
well in either the presence or absence of pulmonary complica- 
tions. In cases of emergency its subcutaneous administration 
works admirably in sweet almond oil, in a twenty-per-cent. 
solution. 

Carbonate of ammonium disorders the stomach more fre- 
quently than camphor is apt to do. Muriate of ammonium has 
no stimulant effect at all. Brandy and whiskey, when of good 
quality and well diluted (at least one in four or five parts of 
water or milk), hold the first rank. That they should, while 
sufficient doses must be insisted upon, not be given at all unless 
indicated, and omitted as soon as no longer wanted, is self- 
understood. Still, I know that they are often continued too 
long, and the occurrence of cirrhosis of the liver in children 
who exhibited no other cause of the disease except the pro- 
tracted use of alcohol for alleged medical reasons, are by no 
means unheard of. Champagne will often take the place of 
brandy and whiskey when speedy stimulation is required, or 
Tokay, Madeira, Sherry, or a California wine, when the former 
are objected to because of their taste. When there is diarrhoea, 
opium given in small doses, perhaps half a minim of the tinc- 
ture every hour or every two hours, to a child of three years, 
will act both as a cardiac stimulant and astringent. Of Sibe- 
rian musk as a powerful stimulant I have seen the best possible 
results. Nitroglycerin in doses of a two-hundredth or one- 
hundredth of a grain, repeated frequently until four or six 
doses have been taken, will be found a vigorous remedy when, 
while the heart is still acting, the arterial pulse is flagging. 



INFECTIOUS DISEASES. 211 

Whatever medicines may be found desirable, the child should 
be kept absolutely quiet. In a recumbent posture it has to 
remain, as a rule; thus the food has to be given, thus it has to 
be carried to the window, or into the open air, if circumstances 
permit. Many a case that looked like being near extinction 
within the four walls will exhibit a wonderful improvement on 
the lawn or under shade-trees. 

Besides, the surface has to be kept warm. It is principally 
the extremities which require external heat. A hot bath, with- 
out or with an aromatic addition, and hot injections into the 
bowels will do a world of good in many a desperate case of col- 
lapse, always provided that the manipulations required are ab- 
solutely gentle and not exhausting. 

To relieve inflammatory complications of the brain in ty- 
phoid fever the hair ought to be cut very short, the head kept 
application of ice-water directly to the heads of small children 
may be washed frequently, or water poured over it while the 
body and throat are protected by an india-rubber cloth. The 
application of ice-water directly to the head in small children 
is not tolerated for a long time. It may give rise to collapse, 
and should be watched carefully. While the head is to be kept 
cool, the feet must be kept warm. Mustard foot-baths and hot 
applications to the feet, cold water or an ice-bag to the heart, 
an ice-bag around the neck, will be found very comfortable. 
When there is the slightest brain complication not depending 
on the infection itself or anaemia, no alcohol should be given, 
no opium, and no caffeine, though it may appear indicated by 
the condition of the heart. The head ought to be kept Eigh 
(low in anaemia), and it is sometimes necessary where the men- 
ingitic symptoms are quite clear to resort to local depletion. 
In these cases the leeches may be applied to the mastoid process 
or, better still, to the septum narium. Where the brain symp- 
toms belong to the infection alone, or to anaemia, opium, how- 
ever, is well tolerated, and relieves sleeplessness and the gen- 
eral irritability. Now and then codeine may take its place, or 



212 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

the hydrate of amylene, chloral hydrate, or sulphonal. Some- 
times the subcutaneous injection of morphine, one or two 
minims of Magendie's solution, will give instantaneous relief. 
Warm bathing will prove beneficial in such conditions of gen- 
eral excitability. In these cases the use of cold must be care- 
fully avoided. 

During convalescence sudden changes in feeding must be 
avoided. I repeat, it is dangerous, to give other than fluid diet 
before the tenth day after the fever has disappeared. After 
that time white meats, plain puddings, and jellies may be 
added. Eaw fruit must not be given under any circumstances. 
Patients should not be taken out of bed sooner than a fortnight 
after their fever has disappeared. Older children should not be 
allowed to read. No visitors ought to be admitted during that 
time any more than during the duration of the disease, for dur- 
ing that very time weakness of the cerebral functions makes its 
appearance or, when met with afterwards, is traceable to it. 
During that time the temperature and the movements should 
still be watched very carefully, for relapses may set in at any 
time. Such relapses are very frequently the result of improper 
food, which will irritate the intestinal ulcerations, the process 
of whose healing is thereby interrupted. The greatest care 
must be taken in those cases in which the spleen, when tume- 
fied during the progress of the disease, will not nearly assume 
its normal size about the middle of the third week. When it 
remains large, a relapse may be looked for. 

The large number of consecutive diseases which may result 
from typhoid fever are ample proofs that all such measures are 
by no means superfluous; multiple abscesses of the muscles, 
ostitis, epiphysitis, and arthritis are not very uncommon after 
typhoid fever. Noma is now and then seen, but it is only just 
to state that epiphysitis and arthritis are not so frequent after 
typhoid fever as, for instance, after scarlet fever, and noma 
not so frequent as after measles. But purpura may remain 
behind. Parotitis is not very uncommon. Thrombi in the 



INFECTIOUS DISEASES. 213 

extremities are sometimes met with. Erysipelas, laryngeal 
perichondritis, and cutaneous gangrene are by no means rare. 
But it is certain that many of these occurrences can be avoided 
if greater care be taken during the progress of the disease. The 
kidneys suffer in typhoid fever as they do in most infectious 
fevers, and frequently at an early stage. The majority of such 
consecutive cases of nephritis are mild and run a favorable 
course. Bad cases will be considered below. 

Among possible complications — not only as the pretext of 
an uncertain diagnosis — we frequently hear of that with ma- 
laria. "Whether typho-malaria is a disease sui generis, as 
Hanson claims for China, may be uncertain. But there is no 
reason why plasmodia and bacilli should not be co-ordinate and 
co-operative. I have seen such cases. Having met with cases 
which appeared to permit the two diagnoses, and mainly such 
which during and after a clear course of typhoid fever devel- 
oped regular attacks of chills and fever, I have administered 
quinine for some time. Several times these attacks appeared to 
be quite grave, and were mostly obstinate. 

5. Typhus. Relapsing Fever. WeiVs Disease. 

The hygienic and therapeutical measures to be taken in 
(petechial) exantliematic typhus are like those of typhoid fever. 
As there are no intestinal symptoms, feeding need not be ex- 
clusively fluid during recovery. 

Relapsing fever permits of solid food in the intermissions. 
The spleen, when very large and sensitive, requires ice-applica- 
tions. Complications with eye- or ear-diseases have their own 
indications. 

Of WeiVs disease (fever, large liver and spleen, icterus, 
nephritis, delirium, coma, erythema, labial herpes) even Ba- 
ginsky has seen but a single case. ("Lehrb.," oth ed., p. 214.) 

6. Epidemic Cerelro-SpinaJ Meningitis. 
It is both endemic and contagious, and demands absolute 
isolation, also rest both for mind and body from the very begin- 



214 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

ning and for weeks or months after recovery. Though the 
prognosis of those cases which do not terminate fatally in the 
first twenty-four hours, and in some of which not even a differ- 
ential diagnosis can be made with certainty, be much better than 
in the different forms of cerebral meningitis, the long duration 
of the disease endangers the result. Noise and glaring light 
must be excluded, no muscular exertion permitted, the neck 
supported; in bad cases of hyperesthesia the bedclothing should 
not be permitted to touch the body. The urinary bladder re- 
quires watching. Leeches applied to the painful spine will do 
some good in the very early stages; an ice-bag, on which the 
neck must be made to rest comfortably, and another one to the 
occiput, and a purgative dose of calomel ought to usher in the 
remedial treatment. Unless contraindicated by great sensitive- 
ness, mercurial ointment externally and iodide of potassium 
internally are expected to do good. The latter is generally 
given in too small doses, and thus misses its effect; from three 
to five grammes (grs. 45-80) daily, and more, are easily toler- 
ated, and are required by a child of five years. Bromides will 
quiet excessive restlessness (doses of 1-4 grammes a day) ; there 
are, however, very few cases but will be greatly benefited by 
sufficient doses of opiates, or chloral, to insure comfort and 
sleep. Sinapisms should be applied for a few minutes at a time, 
and frequently repeated; in the later stages a vesicatory over 
the cervical part of the spine is indicated. I am not pleased 
with the effects of tincture of iodine or iodoform ointments. 
Salicylic acid and salicylates have been praised; but I am 
afraid that the cases in which their good effects were observed 
were those of mistaken diagnoses, for, indeed, rheumatism both 
of the muscles and the meninges has been taken for different 
forms — even the very gravest — of meningitis. The after-effects 
of the disease, particularly paralysis and contractures, are diffi- 
cult to handle; their treatment does not call for any special 
measures dictated by the original disease. Deafness originating 
in the labyrinth or in the acoustic nerve is liable to prove per- 



INFECTIOUS DISEASES. 215 

manent, in spite of hydrotherapy, diaphoresis, and electro- 
therapy. Amblyopia from inflammation of the chiasma and 
the optic nerves gives a bad prognosis; keratitis and panophthal- 
mitis are serious. The actual cautery has been used extensively. 
In the acute stage of the disease it is useless or harmful; in 
the chronic it has been known to do good, and may be applied 
regularly. 

The modern progress of our acquaintance with the etiology 
of infectious diseases adds to our preventive, not yet to our 
curative, powers. H. Jaeger (Zeitsch. f. Hyg. u. Infect., xix. 
p. 351) asserts that sixty per cent, of all cases of cerebro-spinal 
meningitis are connected with or dependent on the pneumo- 
coccus (and diplococcus intracellularis ?). This explains the 
frequent complication with pneumonia. Thus, the nasal secre- 
tion in which the diplococcus is of frequent occurrence requires 
particular attention. Indeed, as early as 1888 the Prussian 
government ordered the disinfection of linen — mainly hand- 
kerchiefs — from this point of view. For the same reason the 
violent aspiration of the naso-pharyngeal secretion, for the pur- 
pose of expectoration, may prove unfortunate for the individual 
and, secondarily, for the community. Weichselbaum, Heubner, 
and Fiirbringer charge the meningococcus intracellularis with 
being the cause. This microbe may also penetrate into articu- 
lations and give rise to a sero-fibrinous exudation, which, like 
the cerebro-spinal, has a tendency to absorption and recovery, 
contrary to the termination of arthritis which depends on 
streptococci and staphylococci. 

7. Glandular Fever. 
Under the name of "glandular fever" Pfeiffer (1887), A. 
Seibert (1894), I. P. West (1896), and Dawson Williams (1897) 
described a complex of symptoms which is claimed as a well 
characterized disease sui generis. Patients were from seven 
months to thirteen years old (Dr. Seibert's case fourteen). 
Parotids not affected. West's ninety-six cases occurred in forty- 



216 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

three families within three years, none during the summers. 
Many of the families lived at a distance from each other, but 
exposure and contagion could be proven in many. Incubation 
mostly seven days (Williams's five to seven to fifteen days, 
mostly seven). Williams also observed many cases in the same 
family. The disease begins with anorexia, malaise, sometimes 
vomiting, some slight diarrhoea, after some days dysphagia. 
There is (Seibert) no pseudo-membrane in the throat, no ton- 
sillitis; in a few cases opisthotonus, which is explained by the 
swelling of the lymph-nodes. Fever moderate, in some cases 
temperature (Seibert) normal in the morning, 104° F. in the 
evening. Some abdominal pain, diarrhoea in milder cases, con- 
stipation in more severe ones. ISTo sequela? and no second at- 
tacks in West's cases. The disease lasted up to six weeks, in 
West's cases sixteen days, in Williams's from four to twenty- 
seven, with an average of sixteen; one death in ninety-six cases 
(West), one in twenty-four (Seibert). The main symptoms 
were the swellings of lymph-nodes, rarely of one side, mostly of 
both, beginning, however, on the left side; the right side fol- 
lowed in a few days. The glandular swellings extend down- 
ward and forward from the angle of the jaw and can be felt 
distinctly and separated from each other (West). The number 
of these swellings varies from four described by West to many 
small hard nodes, distinctly palpable, mostly between the deep- 
seated muscles of the posterior half of the neck (Seibert). Pos- 
terior cervical, axillary, and inguinal lymph-nodes could be 
felt in seventy-five per cent., the mesenteric in thirty-seven 
cases. The liver was found enlarged in eighty-seven cases (by 
Williams in ninety per cent.), the spleen in fifty-three cases (by 
Williams in fifty per cent., by Seibert in none), the tracheo- 
bronchial glands in all of Williams's cases. There was no 
oedema, no suppuration, no permanent enlargement. In the 
discussion of the Pediatric Section of the New York Academy 
of Medicine, Koplik (who never saw a case in his many thou- 
sands of observations) suggested the possibility of an intestinal 



INFECTIOUS DISEASES. 217 

infection because of the fact that the local symptoms started on 
the left side. The reports regarding the existence of an incu- 
bation and the occurrence of contagion cause me to connect 
the affection here, with infectious diseases of a special type, 
for the present. 

8. Catarrhal Fever. 

This is not the "ephemeral fever" of a feverish infant or 
child the cause of which has not been diagnosticated, nor the 
result of overloaded stomach or of intestinal putrefaction, nor 
of cocci in the throat or nose, but of the reflex irritation de- 
pending on "cold," exposure to a cold temperature, or to a 
sudden change of temperature from hot to cold, particularly 
while the skin was perspiring. Sometimes a chill is noted in 
the beginning, or merely a high temperature, aching muscles, 
anorexia, headache, perspiration, and some catarrhal angina, — 
in other cases but little elevation of temperature and perspira- 
tion, but lassitude, sleepiness, and constipation. Labial herpes 
is apt to appear on the second or third day and a copious per- 
spiration is frequently noticed on the fourth or fifth day, after 
which improvement takes place. To speak of a gastric, hepatic, 
or cerebral variety, in order to denote the most prominent 
symptoms, is superfluous. The treatment consists in rest in 
bed, at a temperature of the room of from 65°to 75° F., plenty 
of water (preferably hot), or of hot lemonade for older children, 
a purgative (ol. ricini), tinct. aconiti in one-quarter- to one- 
half -drop doses every hour or every two hours, liquor ammonii 
acetatis from three to ten drops every two hours in hot water, 
and, if there be much headache and a high temperature, phen- 
acetin in one-half- to one-grain (0.03-0.06) doses from time to 
time. 

9. Asiatic Cholera. 

It is almost always fatal in the infant, and little less so up to 
the fifth or sixth year. Its diagnosis is, during an epidemic, 
secured by the presence of the characteristic diarrhoea and 
vomiting, with cold extremities, cyanosis, algidity, and the ab- 



218 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

sence of pulse and of urine; lastly and positively, by the pres- 
ence of the comma bacillus in the faecal discharges. The dif- 
ferential diagnosis should be made from arsenic and tartar 
emetic poisoning, also from very acute nephritis. The latter 
may exhibit the same copious rushing "rice-water" discharges 
of serum with masses of epithelium. 

As the disease is identical with that in the adult, so the gen- 
eral features of the treatment are the same. Preventive im- 
munization has been practised, after many previous attempts 
made in vain, by Haffkin. If his favorable results obtained 
in the East Indies will be confirmed, and the Mecca pilgrimages 
closely watched, the world will be threatened with one less dan- 
ger. During the prevalence of an epidemic no child should be 
permitted to suffer either from diarrhoea or from vomiting. 
Whatever is to pass beyond the lips, mouth-wash or food or 
drink, should be boiled. Invalid or dyspeptic children should 
be sent away, and the schools closely watched for the slightest 
attack of loose bowels. A child suspected of cholera is to be 
kept in bed, with small hourly doses (five or ten milligrammes) 
of calomel, which ought to be continued until the fasces show 
the characteristic color. Creosote may be given in water, salol 
in doses of from five to fifty centigrammes every few hours. 
Hydrochloric acid diluted as a drink, after the administration 
of calomel has been stopped. The extremities should be kept 
warm, the abdomen, if hot and tender, covered with cold appli- 
cations, which are changed when becoming warm, and stimu- 
lants given freely (alcohol, caffeine, strychnine, camphor, tinct- 
ure of musk), subcutaneously if, or because, the stomach retains 
nothing. Warm bathing with friction while in the bath. No 
internal diaphoretics, and absolutely no pilocarpine subcutane- 
ously. For the heart is too feeble; even when the condition 
appears to improve, sudden relapses, and collapse, may turn up. 
The enteroclysis of Cantani (the irrigation to be carried up as 
far into the bowels as possible) is made with a solution of three 
or five parts of tannic acid in a thousand of warm, or hot, water. 



INFECTIOUS DISEASES. 219 

The action of the heart may be re-established by subcutaneous 
salt-water infusions. For these Cantani's original prescription 
contained four parts of sodium chloride and three of sodium 
bicarbonate in one thousand of water. Opium is badly tolerated 
in all stages. High temperatures and delirium demand cold to 
the head; pneumonia, parotitis, nephritis, and other complica- 
tions furnish their own indications. 

10. Dysentery. 

It is communicated from person to person, but by faecal 
discharges only, by the use of the same chamber, for instance. 
Indeed, all the bacillary diseases of the intestinal tract may 
enter through the anus. Privies and sewers are sources of dys- 
entery, as of typhoid fever. The catarrhal, the follicular, and 
the diphtheritic varieties may run their courses separately; in 
many instances, however, the first will only be the initial stage 
of the more serious forms. The treatment is not, for the 
present, influenced by the species of microbes causing or com- 
plicating the malady, bacterium diphtheria?, coli, or amoeba?. 

A patient with dysentery, to prevent communication, should 
be isolated. During the heat of the summer children should 
be protected against colds (the systematic use of cold water is, 
as always, the best prophylactic) and unripe fruit. 

The sufferings from dysentery are so intense, and the dan- 
gers from its acute (fever, convulsions, exhaustion) or chronic 
(scurvy, noma, nephritis, paralysis, diseases of joints) state so 
threatening, that active measures should be taken at once. A 
brisk purgative ought to precede every other treatment. Castor 
oil in sufficient quantities, or calomel — according to age — in 
doses of from one to eight grains (0.05-0.5), will have a favora- 
ble effect, the latter acting both as a laxative and a disinfectant. 

The food should be liquid, milk and strained farinaceous 
decoctions the exclusive diet for the first acute stage. It is on 
the general condition of the patient that the administration 
of other articles of food, such as jellies without sugar, beef- or 



220 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

mutton-broths with farinaceous decoctions, egg albumoses, or 
alcoholic and medicinal stimulants (either general or cardiac), 
will depend in the course of the disease. 

Great sensitiveness of the left hypogastric region and local 
heat will be alleviated by the application of ice. Very young 
infants, however, bear ice but a short time, whether applied to 
head or abdomen. I advise to watch the effect of the applica- 
tion of either the ice-bag or the ice-cold cloth. Now and then, 
even in adults, we meet with an idiosyncratic incompatibility 
with cold, which has to be respected. Indeed, quite often warm 
applications of either water or poultices prove more efficient in 
regard to the two indications, which consist in alleviating irri- 
tation and reducing temperature. 

The subnitrate and the subcarbonate of bismuth do not only 
cover and protect the mucous membrane, but have also a de- 
cided antifermentative effect. Thus bismuth is surely indi- 
cated in irritated conditions of the mucous membrane; it 
seldom fails when given in sufficient doses. There is no harm 
in sometimes giving it in such doses that part of the introduced 
material will pass through the entire length of the intestinal 
tract without undergoing decomposition. As its taste is not 
disagreeable, it may be given together with tannin (gallic acid 
is better) and opium; the daily dose ought not to be less than 
one drachm or a drachm and a half (4.0-6.0). At the same time 
the passages ought to be examined as to their reaction. Abun- 
dant acid, so frequently found in the slightest intestinal anom- 
alies, requires the additional administration of alkalies. Boiled 
milk should be mixed with equal parts of lime-water. In most 
cases carbonate of lime is preferable to either magnesium or 
the carbonate or bicarbonate of sodium, the salts of both of 
which are apt to increase diarrhoea. Sometimes, particularly 
when the stomach can be relied upon, the salicylate of sodium 
may be added to the internal treatment. Besides the favorable 
effect of the sodium in the intestinal tract, the salicylic acid 
may prove beneficial both by its antifebrile and disinfectant 



INFECTIOUS DISEASES. 221 

action. Salol, about one or two grains (0.05-0.15), or resorcin, 
one-quarter or one grain (0.015-0.06), given every two hours, 
may take its place. The latter is better tolerated than the for- 
mer, but salol has a better chance to reach the lower part of the 
intestine. 

Opium and its alkaloids are invaluable in the treatment of 
intestinal ulcerations. The objections to their use are decidedly 
exaggerated. Such accidents as have been reported in isolated 
cases as resulting from the administration of opium is to be 
attributed to the fact that the dose was either absolutely or 
relatively too large, compared with the idiosyncrasy of the 
patient. Dysentery both requires and tolerates larger doses of 
opium than an average diarrhoea, no matter whether the latter 
be the result of catarrh or ulceration of the small intestine or 
the caecum, or the upper part of the colon. In this respect 
dysentery stands abreast almost with peritonitis. The main 
indications are to relieve pain, reduce peristalsis, and diminish 
the copious serous secretion; no other remedy fulfils all of 
them so well. For this purpose it ought to be given internally; 
for enemata containing opium may act favorably, but the more 
intense the tenesmus and the greater the hyperaemia or the 
more extensive the ulceration, the less reliance can be placed 
on their effect, and the amount of the opiate thus brought into 
real action cannot be estimated. Among all the opiates I prefer 
a tincture, or the wine, or opium in substance, or Dover's 
powder; rarely only have I injected morphine under the skin. 
The effect of the drug is easily watched and controlled, by com- 
mencing with moderate doses, not repeating them too often, 
and being guided by the effect obtained. If opium is to be dis- 
carded, opium with hyoscyamus, or with belladonna, or hyos- 
cyamus or belladonna alone, may take its place temporarily. 
Severe tenesmus may require the painting of the protruding 
part with Magendie's solution. 

Astringents may either be given in combination with opium 
or separately. They are expected to pass wholly or partly 



222 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

through the entire length of the intestinal canal, thus coming 
into contact with the inflamed and ulcerous mucous membrane. 
Among those eligible are tannin, gallic acid, and vegetables 
containing the same (ratanhia, catechu), besides subacetate of 
lead, nitrate of silver, and pernitrate of iron. 

The daily dose of gallic acid, when it is to be taken for a long 
time in succession, is from five to fifteen grains (0.3-1.0), sub- 
acetate of lead one to five grains (0.05-0.3), nitrate of silver 
one-fourth to one-half grain (0.015-0.03). The latter ought 
not to be given more than a week, or two, in succession, for fear 
of argyria, two cases of which occurred in my own practice, and 
of my own making, many years ago. All of these medicines 
are best taken, if possible, in the form of pills. They appear to 
be better tolerated, and are certainly more effective. Nitrate of 
silver in solution (distilled water) demands a glass of neutral 
color. 

The use of keratin, when it becomes handier and cheaper, 
will increase the efficiency of pills which are to affect the mid- 
dle and lower part of the bowels only. The keratin covering 
is meant to oppose the solving action of the gastric acid. The 
pills advertised as "intestinal" by a New York firm defy both 
the gastric and the intestinal secretions. 

Another antiseptic which I have frequently administered 
internally in every description of intestinal ulcerations, in both 
the acute and the chronic forms, is naphthalin. For its doses, 
and the methods of its administration, and some account of its 
effect on intestinal ulceration in general, I refer to the chapter 
on typhoid fever. We have to expect a great deal from such 
topical medication, and it appears that it will be one of the 
great aids in all infectious diseases whose principal localization 
is in the intestine, as, for instance, Asiatic cholera. 

Adults will take from fifteen to seventy-five grains (1.0-5.0) 
daily, in powders, capsules, or mucilage. Children bear, 
as a rule, according to their ages, from one-half of a grain to 
two or three grains (0.03-0.2), every two or three hours, in 



INFECTIOUS DISEASES. 223 

some mucilaginous substance. Some do not bear it well, but 
when such is the case, the stomach will give warning at once. 
Its odor, it is true, is objectionable. 

The temperature will but rarely be so high as to require 
antipyretic medication. Frequent enemata will often reduce it 
effectively. Very young infants may demand an occasional 
dose of antipyrin or acetanilide (antifebrin) when the heat 
threatens either the nervous system or the normal structure of 
the tissues of the body. A warm bath will often do better than 
either. 

Consecutive paralysis requires a mild galvanic current in the 
beginning. The daily application both to the spinal cord and 
the extremities need not exceed ten minutes; the electrodes 
should be large, and the current reversed after five minutes. 
After a few weeks the interrupted current may be added the 
same length of time, but it should be applied to the paralyzed 
muscles only. Together with the latter, strychnine or (and) 
phosphorus may be used, in daily doses of one-thirtieth of a 
grain (0.002) in the case of a child of four or five years; the 
former is more effective when used subcutaneously. 

The local treatment of chronic dysenteric ulcerations re- 
quires the use of enemata. Their indications vary. They are 
to evacuate the bowels, or to reduce the irritability of the dis- 
eased intestine, or to accomplish a local cure. These indica- 
tions cannot be fulfilled separately; sometimes two, sometimes 
all three, may be met at the same time. The nature and quan- 
tity and the temperature of the liquid to be injected depend 
in part on the end aimed at, in part on the irritability of 
the individual intestine. Sometimes the bowel objects to the 
introduction of small amounts; sometimes, however, large 
quantities are tolerated very easily indeed. To introduce small 
amounts, the selection of the syringe is a' matter of indifference, 
provided the liquid enters the bowel gently and without pain. 
To inject large quantities, undue pressure and local irritation 
should be avoided. Therefore the fountain syringe alone will 



224 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

answer; it ought to hang but a trifle above the level of the 
anus, say from six to twenty inches. The temperature of the 
liquid is not always a matter of great importance. Some 
recommend the injections to be ice-cold, some, however, tepid; 
both are frequently recommended as panaceas. But the prac- 
titioner will soon ascertain that some bear and require the one, 
some the other, some, indeed, very hot ones. 

In my experience, for the large majority of patients suffer- 
ing either from acute or from chronic dysentery, tepid in- 
jections answer best. Not rarely is the intestine in such a 
condition of irritation that even small quantities of a very cold 
fluid are expelled at once. And again, there are cases in which 
enormous amounts of either cold or warm water are readily re- 
ceived. To accomplish the purpose of evacuating the bowel, 
plain water will often suffice, but three-fourths of one-per-cent. 
solutions of salt in water will usually prove more acceptable. 
Additions of bitartrate of potassium, or castor oil, have proved 
so uncomfortable in my cases that I have discarded them long 
ago. However, when the secretion of mucus on the rectal and 
intestinal mucous membranes was very large, one- or two-per- 
cent, solutions of bicarbonate of sodium answered very well 
indeed. For the purpose of clearing the intestines, either of 
fasces or the morbid products, a single enema is insufficient. It 
ought to be repeated several times daily. When much mucus 
is secreted and tenesmus intense, it may be applied after every 
evacuation. In many cases the substitution of flaxseed tea or 
mucilage of gum acacia will prove advantageous. I have had 
to continue them for weeks for both their evacuating and alle- 
viating effect. When, however, the latter alone is aimed at, — 
that is, when tenesmus is to be relieved, — small quantities will 
usually suffice. An ounce or two of thin mucilage, or starch- 
water, or flaxseed tea, with tincture of opium, or better, with 
extract of opium, prove very comforting. Glycerin in water has 
been recommended for the same purpose. The former alone, 
or but slightly diluted, irritates, nay, cauterizes. It will require 



INFECTIOUS DISEASES. 225 

close judgment and individual experience to ascertain the de- 
gree of dilution, if it be used at all. 

When a local curative effect is aimed at, injections of small 
quantities are sometimes insufficient. As the local lesions are 
often extensive, the amount to be injected must be pretty large. 
Almost always astringents are required. Sulphate of zinc, or 
of aluminium, subacetate of lead, nitrate of silver, tannin, 
chlorate of potassium, ergotin, salicylic and carbolic acids, and 
creosote have been recommended. Of the more common astrin- 
gents I prefer alumina or tannin in one-per-cent. solutions. 
Creosote answered well in solutions of one-half of one per cent 
Salicylic acid resulted more frequently in pain than in benefit. 
Carbolic acid, in solutions of one-half of one per cent., has 
proved very beneficial, but I have learned long ago to be very 
careful in regard to its administration because of its detri- 
mental effects, particularly on the kidneys of very young 
patients. 

Injections of nitrate of silver may prove very useful in cases 
not quite acute. Before the solutions of a quarter of one per 
cent., or of one or two per cent, are injected, the intestine 
ought to be washed out with warm water without salt, or with, 
a two- or three-per-cent. boracic acid solution. After the injec- 
tion has been made it ought to be neutralized with a solution of 
chloride of sodium; it is still better to wash the anus and the 
portion of the rectum within easy reach with that solution 
before the medicinal injection is made. For even the mildest 
solutions, when acting on the sore sphincters, are liable to 
give rise to intense tenesmus when no such care has been taken. 

When the ulcerations are but few, or in the lower portion 
of the bowels only, small quantities suffice. But extensive 
lesions require large injections, the patient being on bis side, 
or in the knee-elbow position. For older children the nozzle of 
the fountain syringe should be lengthened by attaching to it an 
elastic catheter, which is introduced as high up as possible, 
after the same plan that nutrient enemata are to be given. In 

15 



226 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

a number of cases, both mild and severe, where neither the 
usual astringents nor nitrate of silver appeared to answer, I 
have been very successful these twenty-five years, when resort- 
ing to injections of subnitrate of bismuth. The drug is mixed 
with six or ten times its amount of water; of this mixture 
from one to three ounces (30.0-100.0) are injected into the 
bowel, which has been washed out previously, twice or three 
times daily. The result is satisfactory, though a large portion 
of the injected mixture be soon expelled. 

Suppositories containing the above substances may prove 
beneficial. But in order not to irritate they must be so soft as 
to melt readily. They may always contain some opium. But 
its admixture is not always sufficient to relieve the irritability 
of the rectum. Indeed, to accomplish this end opium must at 
least begin to liquefy and to be absorbed, and absorption can- 
not be relied upon except where a part, at least, of the mucous 
surface is in a fair state of integrity. When no suppository 
is tolerated, and the administration of an opiate to the intes- 
tine is indicated, the painting with Magendie's solution, or the 
injection of a small quantity of olive oil with tincture of opium, 
may still be tried. The local application of cocaine relieves 
pain, but the drug is readily absorbed, and great caution should 
be used in its administration because of its poisonous effects. 

11. Scarlatina. 
Preventive measures of the strictest nature are indicated in 
regard to no disease more than to scarlatina. Its mortality is 
very great, in some epidemics even excessive; and when the 
child survives, there may be a large number of sequelae which 
either terminate fatally, or in persistent injury to health, and 
in the curtailing of the enjoyment or usefulness of life. Among 
these are cardiac diseases, glandular affections, suppurative 
otitis, and nephritis. The first attack of the latter is not 
limited to the second or third week, when, it is true, it is mostly 
met with; for I have seen it to appear on the thirty-seventh 



INFECTIOUS DISEASES. 227 

and on the fifty-second day of the disease. Baumler reports 
the case of a child with hemorrhagic nephritis which started as 
late as the forty-fourth day of scarlatina. 

There is another momentous indication for strict prevention. 
The facility of being attacked is by no means so great as, for 
instance, in measles. It is but rarely that any of the young 
inmates of a house escape contagion when measles has attacked 
one of them. The virus of scarlatina, however, is less catching. 
Infants of less than a year suffer but seldom, though very 
severely when taken. The vast majority of those affected, 
however, are less than five years old. After that period sus- 
ceptibility becomes less from year to year, so that, indeed, a 
child that has been protected against scarlatina during its first 
half-dozen years attains a certain degree of immunity for the 
future. 

There is no reason to believe in a primary origin of scarla- 
tina. The efficacy of the virus is so persistent, and it clings 
so long to clothing, bedding, and furniture, that it can be 
carried and transmitted to long distances by persons, towels, 
toys, letters, and even domestic animals and articles of food, 
principally milk. It is transferable through the whole duration 
of the disease, from the incubation to the disappearance of the 
very last trace of desquamation, and perhaps later; even before 
the appearance of the eruption. The incubation of scarlatina 
may last but a few hours, like that of diphtheria and erysipelas, 
or as long as nine days; in this it differs greatly from measles, 
variola, and varicella. The last symptoms may not disappear 
until long after the fortieth day, which, it is true, is the average 
termination. The fine desquamation of the second week may 
have terminated entirely, but the gross peeling, particularly of 
the hands and feet, extends frequently to the end of the seventh 
or eighth week. It carries contagion as well as the desquama- 
tion of the former weeks, or as the breath of the patient, or his 
expectoration in the earlier periods. So slow is sometimes the 
process of elimination that Spottiswood Cameron claims that 



228 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

the end of the disease is seldom reached before the eighth week, 
and not always in the thirteenth. AVhether the urine or the 
alvine dejections of the patient can spread the disease is not 
quite certain; but as long as there is an uncertainty they ought 
to be treated as dangerous elements, and disinfected and re- 
moved. 

Sore surfaces appear to admit the poison. Scarlatina will 
enter through the integuments denuded by eczema. I believe 
I have lost, many years ago, two patients because I operated 
upon them during the prevalence of an epidemic of scarlatina. 
A child of four years, on whom I resected the head of a femur, 
was taken with the eruption on the fourth day and died. 
Another one was stricken down thirty-six hours after the resec- 
tion of a tonsil. In both cases I had reason to believe that I 
opened an inroad to the invading toxin. Indeed, catarrhal or 
otherwise sore tonsils are very likely to furnish a means of in- 
vasion. Several times I observed scarlatina a few days after 
tracheotomy. 

Dispensaries and schools are the hot-beds of scarlatina. A 
single case waiting in the anteroom of a public charity until it 
is seen and diagnosticated may destroy a dozen innocents while 
craving the blessings of public beneficence. Schools ought to 
be closed during an epidemic as soon as a few cases have ap- 
peared. No child coming from a house with scarlatina must 
be admitted. Such as have been removed from the dangerous 
neighborhood and not exposed since may, after thorough disin- 
fection of the clothing worn during the time of exposure, be 
allowed to return after an interval of ten days. 

The daily school inspection of the New York Health Depart- 
ment, organized this year, after the profession had urged its 
necessity from time to time these twenty-five years, cannot fail 
to be very beneficent, and is among the best methods to improve 
public health employed by the efficient health department of 
the city. There cannot be a doubt as to its example being 
imitated in other places. The "inspectors are to carefully ex- 



INFECTIOUS DISEASES. 229 

amine each pupil that has been set apart from the other pupils 
by the teachers of the school, and cause to be excluded from 
schools all those affected with, or showing symptoms of, any 
contagious disease; more especially the following: measles, 
diphtheria, scarlet fever, croup, whooping-cough, mumps, con- 
tagious eye-diseases, parasitic diseases of the head and body, or 
any illness which, in their judgment, shall require the pupil 
to be excluded from school." 

The inunction of the patient with pork, vaseline, and similar 
substances adds to the safety of the attendants by preventing 
the carrying into the air of the eliminated particles of epi- 
dermis. Soaping and bathing contribute to the same end, but 
are not perfectly reliable safeguards because the virus pene- 
trates the whole skin down to the rete Malpighii. 

The sick and their attendants must be strictly isolated; dur- 
ing the winter, when the warm air rises and carries contagion 
with it to the upper part of the house, in the highest story. 
Whoever enters the sick-room — friend, nurse, or physician — 
ought to wear special clothing while inside, or at least a linen 
or india-rubber cover. The physician must disinfect his hands 
after leaving the patient. In the room the air ought to be 
changed often. Draught can be avoided by means of screens. 
No dry linen or clothing must leave the room. It should be 
soaked in water, or better still, in a disinfectant fluid, before 
it is carried off, and boiled in soap and water immediately after 
arriving in the laundry. The same rules which hold good in 
the cases of infectious and contagious diseases in general, and 
those which refer to the disinfection of the room and furniture, 
and public vehicles which may have been used, must be obeyed 
to the letter. No room, in fair weather, will afford the same 
safety as a tent would, and in no disease, with the exception of 
variola and diphtheria, is the erection and maintenance of 
special hospitals more needed than in scarlatina. 

In connection with the question of prevention of contagious 
diseases, scarlatina and others, I cannot render better service 



230 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

than by giving the greatest possible publicity to the directions 
of the New York Health Department. They contain all that 
is known, and all that ought to be done, in city or country, to 
prevent scarlet fever, diphtheria, and measles, in the present 
state of society, and of our knowledge. 

"DIPHTHERIA, SCARLET FEVER, MEASLES. 

"These diseases are very contagious. Diphtheria is usually 
transmitted from the sick to the well by the moist or dry dis- 
charges from the nose and throat of the sick person. Scarlet 
fever and measles are transmitted by the discharges from the 
nose and throat, and also by the scales thrown off from the sur- 
face of the skin. These discharges and scales contain the 
minute germs that cause these diseases. The importance, there- 
fore, of their proper disinfection can be at once understood. 

"Directions to prevent other Cases of Diphtheria, 

Scarlet Fever, and Measles occurring in a Family 

where one case exists. 

"1. If possible, one attendant should take the entire care of 
the sick person, and no one else besides the physician should be 
allowed to enter the sick-room. The attendant should have no 
communication with the rest of the family. The members of 
the family should not receive or make visits during the illness. 

"2. The discharges from the nose and mouth must be re- 
ceived on handkerchiefs or cloths, which should be at once im- 
mersed in a carbolic solution (made by dissolving six ounces 
of pure carbolic acid in one gallon of hot water, which may be 
diluted with an equal quantity of water). All handkerchiefs, 
cloths, towels, napkins, bed-linen, personal clothing, night 
clothes, etc., that have come in contact in any way with the sick 
person, after use should be immediately immersed without re- 
moval from the room in the above solution. These should be 
soaked for two or three hours, and then boiled in water or soap- 
suds for one hour. 



INFECTIOUS DISEASES. 231 

"3. In diphtheria and scarlet fever, great care should be 
taken in making applications to the throat or nose, that the dis- 
charges from them in the act of coughing are not thrown into 
the face or on the clothing of the person making the applica- 
tions, as in this way the disease is likely to be caught. 

"4. The hands of the attendant should always be thoroughly 
disinfected by washing in the carbolic solution, and then in 
soapsuds, after making applications to the throat or nose, and 
before eating. 

"5. Surfaces of any kind soiled by the discharges, should be 
immediately flooded with the carbolic solution. 

"6. Plates, cups, glasses, knives, forks, spoons, etc., used by 
the sick person for eating and drinking must be kept for his 
especial use, and under no circumstances removed from the 
room or mixed with similar utensils used by others, but must 
be washed in the room in the carbolic solution and then in hot 
soapsuds. After use the soapsuds should be thrown in the 
water-closet, and the vessel which contained it should be 
washed in the carbolic solution. 

"7. The room occupied by the sick person should be thor- 
oughly aired several times daily, and swept frequently, after 
scattering wet newspapers, saw-dust, or tea-leaves on the floor 
to prevent the dust from rising. After sweeping, the dust upon 
the wood-work and furniture should be removed with damp 
cloths. The sweepings should be burned, and the cloths soaked 
in the carbolic solution. In cold weather, the sick person 
should be protected from draughts of air by a sheet or blanket 
thrown over his head while the room is being aired. 

"8. "When the contagious nature of the disease is recognized 
within a short time after the beginning of the illness, after the 
approval of the Health Department Inspector, it is advised that 
all articles of furniture not necessary for immediate use 
in the care of the sick person, especially upholstered furniture, 
carpets and curtains, should be removed from the sick-room. 

"9. In scarlet fever and measles, when the patient is begin- 



232 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

ning to recover and the skin is peeling off, the body should be 
washed once daily in warm soapsuds, and afterwards anointed 
with oil or vaseline. This should be continued until all rough- 
ness of the skin has disappeared. 

"10. When the patient has recovered from any one of these 
diseases, the entire body should be bathed and the hair washed 
with hot soapsuds, and the patient should be dressed in clean 
clothes (which have not been in the room during the sickness) 
and removed from the room. Then the Health Department 
should be immediately notified, and disinfectors will be sent to 
disinfect the room, bedding, clothing, etc., and under no con- 
ditions should it be again entered or occupied until it has been 
thoroughly disinfected. Nothing used in the room during the 
sickness should be removed until this has been done. 

"11. The attendant and any one who has assisted in caring 
for the sick person, should also take a bath, wash the hair, and 
put on clean clothes, before mingling with the family or other 
people, after the recovery of the patient. The clothes worn in 
the sick-room should be left there, to be disinfected with the 
room and its contents by the Health Department. 

"Methods of Disinfection. 

"1. Hands and Person. — Standard Solution No. 1 should be 
diluted with an equal amount of water. Hands soiled in caring 
for persons suffering from contagious diseases, or soiled por- 
tions of the patient's person, should be immediately and thor- 
oughly washed in this solution, and then washed with soap and 
water. The nails should be kept perfectly clean and the hands 
should always be carefully disinfected before eating. 

"2. Soiled clothing, towels, napkins, bedding, etc., should 
be immediately immersed in Standard Solution No. 1, and 
soaked for twelve hours, being occasionally moved about in the 
fluid so as to bring the disinfectant in contact with all parts. 
They should then be wrung out and boiled in soapsuds for 



INFECTIOUS DISEASES. 233 

one hour. Articles, such as beds, etc., that cannot be washed 
should be burned. 

"3. Food and Drink. — Food thoroughly cooked and drinks 
that have been boiled are free from disease germs. In presence 
of an epidemic of cholera or typhoid fever, milk and the water 
used for drinking, cooking, washing dishes, etc., should be 
boiled just before using, and all persons should avoid eating 
fruit, fresh vegetables, and ice. Ice may, however, be used 
when ordered for the sick by a physician. 

"4. Discharges of all kinds from patients suffering from 
contagious diseases should be received into earthern vessels con- 
taining Standard Solution No. 1 or 3. Special care should be 
observed to disinfect at once the vomited matter and the intes- 
tinal discharges from cholera patients, as these alone contain 
the dangerous germs. The volume of the disinfecting solution 
used should be at least four times as great as that of the dis- 
charge. After standing for at least one hour in the disinfecting 
solution, these discharges may be thrown into the water-closet. 
Bedding or clothing soiled by the discharges must be at once 
placed in Solution No. 1, and the hands of the attendants disin- 
fected, as described above. 

"5. Closets, Sinks, etc. — Each time the closet is used for in- 
fected material, at least one quart of Solution No. 1 should be 
poured into the emptied pan and allowed to remain there. All 
discharges should be disinfected before being thrown into the 
closet. Sinks should be flushed at least once daily with the 
same solution. 

"6. Dishes, spoons, etc., used by the patient should be kept 
for his exclusive use, should not be removed from the room, but 
should be washed there, first in Solution No. 1, and then boiled 
in strong soapsuds. These washing-fluids should afterwards 
be thrown into the water-closet. The remains of meals should 
be thrown into a vessel containing milk of lime. The contents 
of the vessel, after standing half an hour or more, should be 
thrown in the water-closet. 



234 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

"7. Soiled woodwork, floors, plain furniture, etc., should be 
thoroughly washed with Solution No. 2. Upholstered fur- 
niture, curtains, *or carpets which have been soiled by the 
discharges should be referred to the Health Department for 
disinfection or destruction. 

"It is important to remember that an abundance of fresh air, 
sunlight, and absolute cleanliness not only help protect the at- 
tendant from infection,, but also aid in the recovery of the sick. 

"Note. — The cost of the carbolic solution is much greater 
than that of the other solutions, but generally is to be much 
preferred. When the cost is an important element, the bi- 
chloride solution may be substituted for all purposes for which 
the carbolic is recommended, excepting for the disinfection of 
discharges, eating utensils, or articles made of metal, and of 
clothing, bedding, etc., which is very much soiled. Its poi- 
sonous character, except for external use, must be kept con- 
stantly in mind. 

"Disinfection and Disinfectants. 

"The contagious diseases are caused by minute living germs. 
The object of disinfection is to destroy these. In order that as 
few articles as possible shall be exposed to infection by the dis- 
ease germs, at the very beginning of the illness all unnecessary 
furniture (especially upholstered furniture and curtains), and 
other unnecessary articles, should be removed from the sick- 
room. 

"The following are the best-known disinfectants: 

"1. Heat. — Continued high temperatures destroy all forms 
of life. Boiling for at least one-half hour will destroy all dis- 
ease germs. 

"2. Carbolic Acid. — Standard Solution No. 1 is composed of 
six ounces of carbolic acid, dissolved in one gallon of hot water. 
This makes approximately a five-per-cent. solution of carbolic 
acid. The commercial colored impure carbolic acid will not 
answer for this purpose. Great care must be taken that the 



INFECTIOUS DISEASES. 235 

pure acid does not come in contact with the skin. When 
practicable, the carbolic solution should be used as hot as pos- 
sible. 

"3. Corrosive Sublimate (bichloride of mercury). — Standard 
Solution No. 2 is composed of sixty grains pulverized corrosive 
sublimate and sixty grains of chloride of ammonia, dissolved 
in one gallon of water. This solution must be kept in glass, 
earthen, or wooden vessels (not in metal vessels). 

"The above solutions are very poisonous when taken by 
mouth, but are harmless when used externally. 

"4. Milk of Lime. — Standard Solution No. 3 is made by mix- 
ing one quart of dry freshly-slaked lime with five quarts of 
water. Lime is slaked by pouring a small quantity of water on 
a lump of quick-lime. The lime becomes hot, crumbles, and as 
the slaking is completed a white dry powder results. The 
powder is used to make Solution No. 3. Air-slaked lime has 
no value as a disinfectant. 

"The proprietary disinfectants, often widely advertised, and 
whose composition is kept secret, are relatively expensive and 
often unreliable and inefficient. It is important to remember 
that substances which destroy bad odors are not necessarily dis- 
infectants/' 

The medicinal treatment of mild cases may be expectant. 
Cooling drinks — ten or twelve drops of dilute hydrochloric 
acid in a goblet of water — will often suffice. The food must be 
liquid, or at most semisolid; in the first week milk and fari- 
nacea. Constipation in the first period is aptly relieved by a 
dose of calomel or a vegetable aperient. Diarrhoea, particularly 
in the later stages, requires bismuth, opium, perhaps astrin- 
gents, such as lead, and at all events antifermentatives, such as 
resorcin, salol, or naphthalin; the mild form of stomatitis and 
pharyngitis, half a grain or a grain of chlorate of potassium in 
a teaspoonful of water every hour or two hours. The throat 
complications of scarlatina should be attended to in time, both 
when caused by or attended with streptococci or Klebs-Loffler 



236 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

bacilli. The frequency of the latter varies according to locali- 
ties, seasons, and epidemics. Some observers claim them in fif- 
teen per cent, of all the cases of scarlatina. Eanke found 
pseudo-membranes in sixty-five per cent, of all the recent cases 
at the Munich Children's Hospital. In 53.7 per cent, of mild or 
severe (laryngeal) cases he met with the diphtheria bacillus, in 
38.8 with streptococci. The former were also observed in most 
of those cases in which the pseudo-membranous complication 
arose in the later stages of the disease. That is why he recom- 
mends the use of the diphtheria antitoxin in doubtful cases 
also. This and the general subject of general and local treat- 
ment of pseudo-membranous affections will be discussed in the 
chapter on diphtheria. In most cases (there are exceptions to 
that rule) when they are first observed on the fourth or fifth 
day of scarlatina they are but seldom alarming; when on the 
first day, or previous to the scarlatinous eruption, they are quite 
ominous. In such instances they are often accompanied with 
rapid glandular swelling and serious symptoms of sepsis. Ap- 
plications of ice to the swollen neck will often keep the tume- 
faction within certain limits. When gangrenous degeneration 
of the glands cannot be prevented, and local suppuration occurs 
in the centre, deep incisions and the local use of carbolic acid 
are required in the same manner in which the same affection 
is dealt with in diphtheric diseases generally. In milder cases, 
two applications daily of one part of iodoform in eight or 
twelve of flexible collodion have a good effect. Even they are 
mostly not required, cool applications will suffice. Occasional 
retropharyngeal abscesses require incisions. 

High temperatures do not require very active treatment un- 
less they result in functional or organic changes of the heart 
or brain. As long as these two organs perform their duties 
normally the temperatures may be left alone. A very frequent 
and feeble pulse with a high temperature requires, besides a 
cardiac tonic, quinine, washing with cool water, or water and 
alcohol, cold applications to the heart, or a warm bath. A cold 



INFECTIOUS DISEASES. 237 

bath is not borne well; in urgent cases a cold pack may do 
good. A feeble and arhythmic pulse requires the very strongest 
stimulants. Antifebrin and antipyrin are not to be recom- 
mended in these conditions. Delirium and somnolence, also 
convulsions, may be the results of high temperatures, and, par- 
ticularly when the whole body, feet included, is hot, require 
the same treatment. Antipyrin, however, I have never seen to 
reduce the temperature in congestive or inflammatory condi- 
tions of the brain. The latter may be the direct result of the in- 
fection, but also at a somewhat later period of rheumatism. In 
either case the treatment does not materially differ from what 
it would be under ordinary circumstances. The latter form 
requires salicylates, the application of ice to the head, counter- 
irritants to the feet (sinapisms) and intestines (calomel), and 
in some cases leeches to the septum narium or to the mastoid 
processes. The vital indication proceeding from the condition 
of the brain is here of the greatest importance. 

When the same symptoms set in with or without a high rectal 
temperature and cold extremities, a mottled skin, and a cya- 
notic hue, the large amount of the toxin which has invaded 
the system demands strong stimulants, — ammonia, musk, and 
camphor. They act better than alcohol. To their internal 
administration may be added camphor dissolved in almond oil, 
and sulphate of sparteine in water, subcutaneously, in free and 
frequent doses. These toxic symptoms while the temperature 
is but low bear opiates (morphine, one-fiftieth or one-twentieth 
of a grain, one to three milligrammes), in repeated doses, quite 
well. Universal heat requires tepid bathing, with cold affu- 
sions over, or applications to, the head; a cool surface, with 
cold extremities and frequent and filiform pulse, hot bathing 
and powerful friction, and hot enemata, with stimulants. 

Vomiting before and with the eruption is a frequent symp- 
tom. When moderate, it may be left alone; no food must be 
given for a number of hours, ice-water in teaspoon doses, or 
an ice pill, every five or fifteen minutes. When quite severe 



238 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

and exhausting, small doses of an opiate, once every hour or 
two, will be found useful. In a few obstinate cases the muriate 
of cocaine in doses of one-twentieth or one-fifteenth of a grain 
answered well; in others, arsenous acid, every two hours, a 
two- or three-hundredth part of a grain (one-third or one-fifth 
of a milligramme). 

One of the early complications is rheumatism. It makes its 
appearance often on the third or fifth day. In some cases it 
is muscular, and then mostly confined to the lower extremities; 
in others articular, but with less swelling than we are inclined 
to expect. Indeed, articular rheumatism in children exhibits 
the usual symptoms to a less characteristic degree than in 
adults, but they are so pronounced as not to be mistaken. This 
rheumatism ought to be treated at once, for endocarditis com- 
plicates it in infancy and childhood very much more readily 
than in advanced age. Most of the cases of scarlatinal endo- 
carditis carried into later life are due to rheumatism. The 
joints ought to be well covered with soft cotton, and salicylate 
of sodium given every two or three hours in doses of from four 
to ten grains (three to ten decigrammes). 

Endocarditis and pericarditis, without rheumatism, are but 
rare occurrences. Ulcerous endocarditis I have not seen except 
with serious general sepsis, caries of bones, thrombosis of a 
sinus, and other symptoms of a general pyaemia. 

Suppurative inflammations of joints are very rare. They 
are the cause, or part, of generalized pysemia. This can be 
prevented sometimes by early surgical treatment. There is an 
affection of the epiphyses, however, which is very common and 
differs from the above. It consists in extensive hyperemia, 
and possibly inflammation. Clinical observation yields quite 
a number of cases of infectious diseases, but mainly scarlatina, 
in which during convalescence, and long afterwards, the re- 
gions of the joints are swollen and painful. This epiphysitis 
is the cause of the rapid increase in the growth of children who 
have passed through scarlatina, but may also be the cause of 



INFECTIOUS DISEASES. 239 

serious changes, from simple "growing pains" to suppurative 
separations of the epiphysis from the diaphysis. In every such 
case, during convalescence and afterwards, the joint ought to 
be well supported by soft splints, and emplastr. hydrarg., or 
iodoform collodion, absolute rest enjoined, and phosphorus 
given in- three daily doses of a two-hundredth of a grain (one- 
third of a milligramme), or more, several times daily. 

Complications with pneumonia and pleuritis are quite fre- 
quent; the latter is apt to be purulent; if so, its existence 
explains in many cases the continuance of the high tempera- 
ture. In every case, purulent or not, the indications are not 
those of an expectant plan of treatment. Both general and 
cardiac stimulants and tonics are required, and pyothorax re- 
quires an operation. 

Hemorrhages are not frequent, but ominous when they 
occur. Some appear like the symptoms of generalized purpura, 
more towards the end of the malady, some in the muscles in 
the third week or later with the result of starting a more or 
less universal myositis, others in the mucous membranes. 
Many are the result of embolic processes, and complicated with 
local gangrene. Spontaneous thromboses, however, of the ex- 
tremities, or the cheeks ("noma"), are not so frequent in scarla- 
tina as they are in measles. 

The presence of pemphigus during the eruption appears to 
indicate a high degree of vasomotor paralysis. It is an ominous 
complication and requires stimulants as above. Urticaria is 
more troublesome than dangerous. The inunction with pork, 
vaseline, glycerin, or lanolin — soothing and pleasing in most 
cases of scarlatina — may suffice to relieve it. Now and then 
mild alkaline lotions (bicarbonate of sodium in water, 1 : 100), 
or the washing with carbonated alkaline waters (from the 
siphon), or with a proper dilution of carbolic acid (1 : 200), will 
prove beneficial. When the burning and itching is quite an- 
noying, naphthol five parts, and vaseline one hundred or one 
hundred and fifty, may be tried to advantage. 



240 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

The rules for the general treatment of scarlatina must 
necessarily be very much like those applicable to all infectious 
diseases. Thus in regard to them, and particularly to the de- 
bility and failure of the heart, I refer to my remarks on the 
treatment of patients suffering from typhoid fever. In scar- 
latina, and eruptive fevers generally, there is, however, an ad- 
ditional indication resulting from the participation of the skin 
in the process. Indeed, more than in other diseases, the hy- 
giene of the surface is to be attended to. During the course of 
the disease, particularly during desquamation, a tepid bath, 
with soap, ought to be given from time to time, and the tem- 
perature of the room and bed kept equal. While the former 
is to be cool, the body must be well covered and kept warm. 
This is the more necessary, as nephritis may set in at any time 
during many weeks. This serious complication, it is true, may 
occur though the patient be kept in bed, in consequence of 
voluminous elimination of renal epithelia, and also, perhaps, 
of bacteric invasion, but exposure and sudden changes of tem- 
perature will always hold their place in etiology, in the minds 
of those who do not forget to notice the living clinical case 
besides the microscopical excrement. 

In this connection, while I reserve the subject of nephritis 
for some future occasion, I will only urge the advisability of 
beginning the treatment of scarlatinal nephritis with a moder- 
ate dose, one-half to one grain (0.03-0.06), of calomel, repeated 
from time to time, through the first two or three days. Its pur- 
gative effect, if too great, may be stopped by a small dose of 
opium given after every loose movement. 

There are a great many other complications, such as otitis 
media, purpura, noma, onychia, keratomalacia, etc. Each of 
them will be discussed in their proper places. Mere combina- 
tions with other diseases, such as whooping-cough, measles, 
varicella, vaccinia, variola, and typhoid fever, do not add to, or 
alter, the indications for treatment. At all events the belief 
in scarlet fever specifics should be discarded in the state of our 



INFECTIOUS DISEASES. 241 

present knowledge. Neither sulphite of magnesium or of so- 
dium, nor benzoate of sodium, nor belladonna have fulfilled the 
promises of their sponsors. What some special antitoxin will 
do remains to be seen. Marmorek's streptococcus antitoxin is 
still in its experimental stage. If anywhere, an antitoxin is the 
only possible remedy which could hold out any hope in those 
cases which perish in a day, sometimes in the very first few 
hours of the illness, under the influence of an overwhelming 
intoxication, and are not relieved by hot bathing, or purging, 
or stimulation.* 

12. Measles. 

The virus of measles appears to be more volatile than that 
of any of the other contagious diseases with the exception of 
influenza. Its communicability appears to be greatest during 
the prodromal stage, and the invasion takes place, in all proba- 
bility, through the bronchial mucous membrane. The incuba- 
tion may last thirteen days, the first four or five of which may 
be attended with some fever. During all this time, and during 
its whole course, the disease is contagious. 

Very few cases are seen during the first six months of life. 
After that it is common, and repeated invasions are frequent. 
In many seasons the mortality is very trifling; in some epi- 
demics it has reached thirty-three per cent, of all the cases. 
The first epidemic occurring in regions where measles had 
not been known previously was found to be very dangerous, 
and those which occur after long interruptions are likely to 
prove very severe. Thus the question whether the well should 
be separated from the sick will depend a great deal on the 
severity of the epidemic. 

* In their studies on the antitoxic and therapeutical effect of human 
blood after infectious diseases, O. Huber and F. Blumenthal (Berl. klin, 
Wocli., No. 31, 1897) come to some positive conclusion. They believe 
they have found specifically healing factors which, in their opinion, need 
only concentration to prove useful in scarlatina, measles, and also in 
pneumonia. 

16 



242 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

The temperature of the room should be comfortable, a little 
warmer than in scarlatina, and the air moist. The light ought 
to be excluded to a certain extent, but not to absolute darkness. 
For a number of days the child should be kept in bed, unless 
very restless; in that case it may be taken out well covered. 
It is a good rule to keep the patient in bed a week after the 
disappearance of the fever, and in the house ten days or a fort- 
night longer. Eelapses are not uncommon, and those particu- 
larly who have a hereditary tendency to tuberculosis ought to 
be protected from exposure. Especial care must be taken dur- 
ing the cool or rainy season. 

Mild cases require mostly a hygienic treatment only; still, 
every case has its own indications. Where there is otitis, bron- 
chitis, pneumonia, or dysentery, it is self-understood that the 
patient must be kept in bed during the continuance of the 
complication. Warm and dry weather and a sandy soil will 
permit a patient to leave the house sooner than he would be 
permitted to do under other circumstances. 

Constipation may demand gentle treatment in the begin- 
ning. As a rule, an enema will suffice. Castor oil or the elixir 
of rhamnus purshiana may sometimes be required. No drastic 
should be used because of the tendency to diarrhoea or dysen- 
tery prevailing in many instances. For the same reason no 
glycerin should be injected into the rectum. 

A convulsion in the beginning of the disease does not always 
mean great harm. It takes the place of the chill in the adult, 
but is more dangerous because of the possibility of hemorrhages 
occurring while it lasts. Thus it ought to be cut short as soon 
as possible. Chloroform inhalations will relieve the spasm, 
chloral hydrate internally, or in an enema, the persistent irri- 
tability. Warm bathing may be resorted to when under these 
circumstances the eruption is slow in showing itself. The head 
is to be kept cool, the feet should be warmed. 

Epistaxis may be left alone while mild. Sometimes it re- 
lieves the congested mucous membrane of the nares. When 
severe it has to be stopped. 



INFECTIOUS DISEASES. 243 

The organs of circulation do not suffer often in measles. 
Pericarditis and endocarditis are met with very rarely, but 
Baginsky reported a case of purulent pericarditis and myocar- 
ditis. In epidemics of unusual severity heart-failure is of fre- 
quent occurrence. It is to be treated according to the prin- 
ciples laid down in the articles on scarlatina and typhoid fever. 
A peculiar feature in very severe measles is the frequency of 
thromboses. Indeed, in no other infectious disease are they 
met with as often as in measles. The thrombi occur in the 
vulva, in the skin and subcutaneous tissue, about the face as 
cancrum oris (noma), on the distal parts of the extremities, 
particularly the legs. Disseminated purpura is not frequent, 
but gangrene of the skin is not at all uncommon. The odor 
of such gangrene, and of cancrum oris, is very offensive indeed, 
and requires strong disinfectants and deodorizers. Thymol in 
solution of one to one thousand, iodoform in powder or in vase- 
line ointment, will be found serviceable. The subject of noma 
will be discussed in another chapter. 

What has been called hemorrhagic measles is not always very 
malignant. In a great many cases it means nothing but the 
effusion of some haematin into the eruption. The complication 
of the eruption with a simple erythema, or with pemphigus is 
mostly an indifferent matter. 

The respiratory organs suffer mostly in measles. There is 
always catarrh of the nose, which may lead at an early period 
to tumefaction of the lymph-bodies around the neck. If such 
be the case the catarrh should not be left alone, but treated 
with gentle injections of a mild solution of salt water or boracic 
acid. The conjunctivitis connected with it requires tepid or 
cool application, or instillation several times a day of a few 
drops of a two-per-cent. cocaine solution. It should have close 
attention, for it is sometimes followed by destructive processes 
of the cornea. A moderate amount of bronchial catarrh may 
be left alone provided the cough is not very severe, for severe 
attacks of coughing, even without much congestion or inflam- 



244 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

mation, may produce bronchiectasis or emphysema. Particu- 
larly is this the case when there is complication with pertussis. 
Here morphine may be given in" sufficient doses. Bronchitis 
is rarely dangerous unless it be capillary. Broncho-pneumonia 
is always a serious complication and a very frequent one. In 
a number of cases its course is very rapid, accompanied with 
cyanosis and a very small pulse. Active treatment is required 
in these cases. The inhalation of oxygen will now and then 
bridge over urgent conditions. Warm bathing and cold affu- 
sion in a warm bath will be of good service, for it is necessary 
that the patients, particularly small children, should cry. Un- 
less they cry they will suffocate. Stimulant expectorants are 
in order, such as camphor, benzoic acid, or carbonate of am- 
monium. The muriate of ammonium is not sufficient. Cardiac 
stimulants are required at the same time, such as digitalis, 
sparteine, and musk. jN"o depressing expectorants should be 
given. Antimonials should be avoided at any rate. 

There is always some catarrh of the larynx and sometimes a 
pseudo-membranous laryngitis holding, or caused by, either 
cocci or Klebs-Loffler bacilli. In the latter case, the treatment 
is that of diphtheritic deposits. (See chapter on Diphtheria.) 
When the croupous symptoms are very urgent the air of the 
room ought to be filled with steam, and the patient encouraged 
to drink as much as possible, particularly of alkaline waters. 
The internal administration of the iodide of potassium in mod- 
erate doses will do good service. So will an opiate, particularly 
at bedtime. In connection with the catarrhal affection of the 
nose, otitis is seen now and then. According to Schwartze, 
three per cent, of all the cases of otitis can be traced back to 
measles. 

During all this time the kidneys ought to be watched. It 
is true that nephritis is by no means a frequent occurrence in 
measles, but it has been found often enough to justify the 
greatest attention. 

Cerebral complications have no special indications. Eules 



INFECTIOUS DISEASES. 245 

for their treatment will form the subject of a future discussion. 
Meningitis as one of the localizations of tuberculosis, which 
often follows measles, is not infrequent. 

13. Rotheln (Rubella). 
It has not yet conquered an indisputable place in pathology. 
There are still many who do not take it to be a separate disease. 
The eruption looks mostly like measles, sometimes like ery- 
thema, or urticaria, or scarlatina. According to some it begins 
on the face, others deny that and speak of a suffused blush 
only. Many cases have been described which were connected 
with catarrh of the respiratory organs and of the throat, with 
glandular swellings (submaxillary, mastoid, axillary, inguinal) 
and very moderate fever. These are the cases which have been 
described under the name of rubella morbillosa, and would be 
diagnosticated by many, myself included, not as rotheln, or 
rubella, but as a mild form of measles. If there be any such 
special disease, no special treatment is required, except that of 
complications (catarrh, coryza, conjunctivitis, bronchitis, men- 
ingitis, arthritis, albuminuria), most of which are rare. 

14. Mumps. 
Its incubation lasts a fortnight, and sometimes three weeks. 
Thus prevention by isolation can seldom be accomplished. The 
infection must be presumed to take place through the Steno- 
nian duct. Thus a careful hygiene of the mouth should be con- 
sidered the best preventive. Often the patients do not feel 
very sick. Many do not take to their beds. In many cases 
covering the swelling with cotton is sufficient to protect it. 
Where there is a great deal of pain narcotic applications may be 
made, or ice applied. The latter certainly reduces the amount 
of swelling, although it may not shorten the course of the 
disease. I have often found the application of iodoform col- 
lodion (one to eight or ten), made twice a day over the whole 
surface, quite successful. When there is a tendency to suppu- 



246 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

ration, warm applications will favor it. Then a large incision 
must be made in time, and treated antiseptically. The diet 
must be that of all fevers, — fluid. A consecutive anaemia which 
is more frequent than the apparent mildness of the affection 
would seem to explain, requires generous feeding, iron, nux, 
and a change of climate. Complications with otitis, nephritis, 
or orchitis have their own indications. 

15. Variola. Variolois. 

Vaccination ought to take place early, for genuine variola in 
the first year is quite frequent among those not vaccinated. 
There are also many cases of variola among those not vacci- 
nated between the eleventh and twelfth years. The small-pox 
reports of the German empire emphasize the fact that no case 
of variola (variolois) occurring in vaccinated children who had 
more than two cicatrices terminated fatally; nor was there a 
fatal case among those who were revaccinated. There was no 
fatal case where the vaccination marks were very distinct, be- 
tween the thirteenth and forty-fourth years. The fact that 
none died that exhibited more than two marks appears to 
prove that the single mark customary among us may not be 
sufficient. At all events, many of our children vaccinated in 
the first year of life will undergo a successful revacciu^tion 
when they are only from four to six years old. At that time 
revaccination ought to be tried, and if unsuccessful, should be 
repeated from year to year. 

Isolation is now recognized as an absolute necessity more 
in a case of variola than in any other disease. Thus little diffi- 
culty is caused by ill will or ignorance. Patients with variola 
ought to be kept cool, washed frequently with cold or tepid 
water; now and then an ether spray or an ice-bag over sore 
parts will be found quite agreeable. Fever is sometimes very 
high, and ought then to be modified by antipyretics. The 
delirium is sometimes so violent, and bordering on mania, that 
the inhalation of chloroform or the administration of chloral 



INFECTIOUS DISEASES. 247 

hydrate is required. The influence of universal compulsory 
vaccination cannot be shown better than by the report of Ba- 
ginsky, who has not met, in children, a single case of genuine 
variola, and but few of variolois. The eyes ought to be covered 
with cold compresses, sore eyelids covered with vaseline or zinc 
ointment. Superficial sores on the skin, and those which yield 
an offensive odor, should be treated with thymol, salicylic acid, 
or iodoform. Scabs must be removed from the nostrils so as to 
facilitate respiration; abscesses should be opened in time and 
disinfected, and complications treated. One of the most severe 
complications is oedema of the larynx, and laryngitis, which 
may require, on short notice, tracheotomy or intubation. 

After the disappearance of the feverish stage the patient 
ought to be bathed once every day or every other day, and in- 
unctions of fat made all over the surface until desquamation is 
complete. 

16. Varicella (Chichen-Pox). 

When varicella vesicles are in the mouth, they require washes 
with chlorate of potassium (1 : 30-50), when on the vulva, 
dermatol powder, or dermatol with cold cream (1 : 6-8). Con- 
stipation and gastric symptoms should be relieved. As the 
disease is very contagious, and not always mild, the child ought 
to be isolated, and on no account sent to school. Dissemination 
in schools and in dispensaries is an every-day experience. 

Bad cases must be kept in bed. Very few require medicinal 
treatment, except when there is local or disseminated gangrene, 
which I and many others have seen. A small number of in- 
stances of consecutive nephritis are now on record, as also in 
vaccinia; thus the urine ought to be examined in every case. 

17. Vaccinia. 

Irregularities in the development of vaccinia cannot always 

be prevented. The appearance of the vaccination vesicles (and 

pustules) will be delayed sometimes without an apparent cause. 

Accidentally (transmission by scratching) they may come on 



248 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

distant parts. A universal eruption (from no such cause) has 
been reported by Colcott Fox (Lancet, 1893, i. p. 362) and 
one case by Baginsky ("Lehrb. d. Kind.," 5th ed., p. 178). 
Very high temperatures with nervous symptoms may require, 
in rare instances, an antipyretic treatment; they accompany 
mostly a high degree of local inflammation, which will be 
soothed by the application of cool water or of diluted aqua 
plumbi. Ulcerations result mostly from uncleanliness and 
from scratching. They may be prevented by great care and 
cleanliness in vaccination, which requires the same asepsis as 
any other operation. No plaster should be applied before the 
wound is perfectly dry. Moreover, they appear to be more 
frequent when humanized than when animal lymph is used. 
Iodoform, or dermatol, in powder or in ointments are indicated. 
Axillary lymphadenitis disappears, with very rare exceptions, 
with the local inflammation. Rhachitis, scrofula, and tuber- 
culosis, when they are observed after vaccination, are acci- 
dental. Syphilis has been transmitted when the serum taken 
from the arm contained blood of a syphilitic infant; that 
is another reason why animal lymph should be uniformly 
preferred. Erysipelas does not always originate from the 
margin of the local inflammation, but sometimes at some 
distance. Neither in regard to prevention nor to treatment 
can anything be said in addition to the remarks on erysipelas 
in general (p. 249). Diphtheria would arise from vaccination 
wounds, when we knew less about its communicability and its 
preventability, and were more careless than we are (?) at 
present. The local treatment of such accidents (or sins) will 
be discussed under Diphtheria. At the very height of the 
reactive inflammation, or in the week succeeding it, urticaria 
may appear, or small or large vesicular eruptions; which 
are liable to disappear with the desiccation and falling off 
of the scabs. They should be considered as nervous oufc 
breaks only, and not be considered in the same light as an 
eczema — local or universal — which dates from the time of vac- 



INFECTIOUS DISEASES. 249 

cination. The latter should not be taken for its real, but for 
its proximate cause (the fever) and opportunity. 

18. Erysipelas. 

It is so communicable that even a physician may carry it. 
Still, it is not probable that the healthy surface can be attacked 
by it. As in most cases of diphtheria, so in all cases of ery- 
sipelas, a sore surface forms the resting-place of the microbe 
(streptococcus). Erysipelas may make its appearance on an 
eczematous skin. On the head it sometimes escapes notice for 
some days. Excoriations of the anus and sexual organs, or 
slight injuries done by a pin or by the finger-nail, are sufficient 
to cause it. It often originates in the intertrigo of the infant, 
or in the neighborhood of a vaccination mark. In the latter 
case it seldom appears immediately after vaccination, very often 
not before the second week or later. Chronic nasal catarrh is a 
frequent cause. Some children will have erysipelas extending 
over both cheeks one or more times every year. Slight or large 
operation wounds are a frequent source; so is diphtheria with 
which erysipelas is occasionally complicated, and many cases 
are seen to take their start from a tracheotomy wound. In the 
newly-born it appears, as a rule, on or near the navel, and is 
generally connected with universal sepsis. Prevention of the 
disease will mainly depend on the removal, or relief, of the 
several causes which have been enumerated. 

Every case of erysipelas should be isolated, and diet and 
general treatment be regulated on general principles. The 
local treatment may be quite simple in some cases. The ery- 
sipelatous surface may simply be covered with soft cotton, or 
a powder of talcum, or of amylum, or one part of salicylic acid 
with perhaps ten parts of oxide of zinc and twenty-five of 
amylum. Applications of lead wash and opium, or of sulphate 
of zinc, have been in general use for a long time; also of solu- 
tions of sulphate of iron; now and then the application or in- 
unction of blue ointment. The latter I cannot advise because 



250 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

of the pain and irritation resulting. The inflamed surface has 
been covered with collodion. Infants and children will not 
bear it. Ferreire has used, in a case of erysipelas on the leg of 
a child of two years and a half, a mixture of one part of resorcin 
in seven thousand five hundred of traumaticin (0.008 : 60.0). 
Cold applications have been made, ice has been applied, and 
where the extent of the erysipelas is but limited, to great ad- 
vantage. Neither saturated solution of nitrate of silver nor the 
solid caustic have been of advantage. 

Hueter recommended many years ago the subcutaneous in- 
jection of a two-per-cent. solution of carbolic acid round the 
inflamed surface, and claimed to have confined every case 
within its original limits. In place of that, I advised the ap- 
plication, not on, but around, the erysipelatous area, of a mix- 
ture of one part of carbolic acid in eight, ten, or fifteen parts 
of oleic acid. I have treated many cases in that way, and most 
of them quite successfully. The application was rubbed into 
the surface around the diseased part at frequent intervals, or, 
when the erysipelas was confined to the extremity, a band or 
compress soaked in the mixture was applied just outside the 
diseased part, not infrequently with the result of stopping the 
process. Instead of the carbolic acid as administered by Hueter, 
Ducrey uses a solution of one part of corrosive sublimate in 
one thousand of water, and repeats the injections, which are 
to be made three centimetres apart, after twelve hours. A 
better plan, however, is, after all, to apply carbolic acid, one 
part dissolved in ten or fifteen of alcohol, directly to and 
beyond the surface, every hour or every few hours. It is readily 
absorbed, and may do good, but also harm by affecting the kid- 
neys. Thus in every case where it is to be applied the kidneys 
should be watched carefully, and particularly in young children. 

Washing with and applications of a solution of bichloride of 
hydrargyrum in water (1 : 2000) have been highly recom- 
mended; also an ointment of resorcin five parts and vaseline 
and adeps lanse hydrosus (lanolin) aa ten parts. I have seen a 



INFECTIOUS DISEASES. 251 

few cases doing well with it, but I have been better pleased with 
a mixture of equal parts of ichthyol (sulpho-ichthyolate of am- 
monium) and vaseline. In place of this a solution of ichthyol 
(2-10) in equal parts of ether and glycerin (10-30) has been 
employed. The compound tincture of benzoin may be painted 
all over and beyond the diseased surface once every hour or 
two hours. Absolute alcohol (ninety-nine per cent.) applied 
frequently, has rendered me excellent service in limiting the 
area of infection. That is what is aimed at and accomplished 
by the hedging in of the morbid process, an operative procedure 
invented by Kraske and Riedel, and introduced to us by Willy 
Meyer. Eailfence-like scarifications are made under an anaes- 
thetic, down to the rete Malpighii, partly in the diseased and 
partly in the healthy surface, double so as to cross one another 
and allow no loophole. Then corrosive sublimate (1 : 500) is 
rubbed into and kept applied to the wounds, in most cases with 
almost instantaneous, at all events rapid, success. The modifi- 
cation of this procedure, which is practised in one of the large 
children's hospitals of Germany, by incising the erysipelas and 
squeezing with the intention of removing the cedematous in- 
filtration of the tissues, then scarifying deeply around it and 
rubbing in ichthyol, and repeating that "treatment" until 
scurfs are formed, appears to get dangerously near criminality. 

The internal administration of the tincture of chloride of 
iron has been considered a specific by many. That opinion is 
certainly based on an exaggeration of its merits. The prep- 
aration is, however, an antifermentative, and, while being a 
vascular stimulant, does not give rise to fever in infectious 
diseases as it would do in simple inflammatory fevers. 

Abscesses complicating erysipelas require large incisions and 
antiseptic treatment. Erysipelas of the neck is very often com- 
plicated with oedema of the larynx, and may require scarifica- 
tion, tracheotomy, or intubation. 

Meningitis which frequently accompanies erysipelas of the 
scalp, or of the naso-pharynx, has its own indications. It 



252 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

should not be forgotten, however, that many cerebral symptoms 
simulating meningitis and mostly attended with high tempera- 
tures, are merely those of the toxin infection, and an antiseptic 
treatment may do good. The recovery of a young man observed 
with such symptoms lately I attribute solely to the large quan- 
tities of brandy administered. In such cases a streptococcus 
antitoxin, such as Marmorek is trying to furnish, could be of 
incalculable benefit. 

19. Diphtheria. 

The morphological structure of the pseudo-membranes in the 
throat, nares, larynx, and other places is identical. They 
have mostly been studied in the throat, where they are most 
frequently found. They consist of finely reticulated fibrin 
holding exudate cells, leucocytes, and some erythrocytes. 
When they are superficial, it is the epithelial protoplasm 
which is thus transformed; when they are deep-seated with 
a tendency to necrosis, ulceration, and, finally (in cases of 
recovery), cicatrization, it is the fibrillar basic substance of 
the connective tissue, mostly of the mucous membrane, some- 
times also of the submucous and deeper structures. This 
view, which underlies the discussions in my "Treatise on 
Diphtheria" (1880), has been again forcibly demonstrated, 
lately, by P. Baumgarten (Berl. hlin. Woch., Nos. 31 and 32, 
1897). For some years, however, it was customary to differen- 
tiate between those pseudo-membranes which are caused by, or 
accompanied with, the Klebs-Loffler bacillus, and those which 
contain streptococci. That these microbes do not establish any 
disease by their mere presence, that, on the contrary, they are 
met with, to an indefinite degree, in the mouths of the healthy 
is well understood. To be considered pathological, or patho- 
genous, their presence in a pseudo-membrane in whatever stage 
of development is required. The Klebs-Loffler bacillus is 
found in its superficial layers only, and not throughout the 
whole thickness of the pseudo-membrane; the coccus pervades 
its whole substance, and is even found in greater numbers in 



INFECTIOUS DISEASES. 253 

the deeper layers. To explain the absence of bacilli from these, 
it is assumed that they are destroyed by other microbes. Still, 
they are assumed — and that assumption has become an axiom, 
an article of faith — to evolve the toxin which gives rise to all 
the symptoms and dangers of certain forms of diphtheria. 

Pseudo-membranes with Klebs-Lomer bacilli are called by 
almost universal agreement, diphtheritic, those with cocci 
pseudo-diphtheritic; those cases which carry both bacilli and 
cocci are called mixed infections. It has been claimed that the 
second class is of little virulence, and attended with but little 
danger. This opinion leads to cruel mistakes in their manage- 
ment both by boards of health and such medical men as are 
influenced by them. For not only are many uncomplicated 
cases very grave and fatal, but the mixed infections are the 
very worst forms met with in practice. Moreover, the strepto- 
coccus cases are contagious. Still, it is important to mention 
at once, that the differentiation has its great practical weight. 
For it is only the first class, the bacillary diphtheria, and 
the third, which are favorably influenced by antitoxin. The 
streptococcus variety does not share that advantage. What I 
have to say of treatment, however, refers — always with the ex- 
ception of antitoxin — to all varieties. It will be for the atten- 
tive and experienced reader to apply it to the individual case, 
mild or serious, local or generalized, acute or chronic. Between 
these two latter varieties, however, the accurate differentiation 
is impossible, because diphtheria has no limited course. There 
are cases that last a week or less, there are those that take many 
months. Not a few of the latter (see my "Treatise") require, 
besides the general treatment, a very careful local diagnosis and 
treatment, as they are in part caused or prolonged by a local 
ulceration, tonsillar or peritonsillar abscess, or concrement, or 
other foreign body. 

Local diphtheritis, constitutional diphtheric infection, and 
diphtheric sepsis are different degrees of the same disease. The 
first may run a fairly mild course, or be the initial stage of the 



254 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

second and third. The treatment, accordingly, may be simple 
or complicated, successful or in vain. It should be preventive, 
local, increase the power of resistance to the toxin prepared by 
the bacilli and floating in the circulation and in the tissues, be 
directly antidotal, and be aimed against the results of the dis- 
ease, such as swelling of the lymph-nodes, laryngo-stenosis, 
nephritis, and paralysis. In many cases it may be only neces- 
sary to fulfil but one or two of these indications, in others a 
combination of measures and remedial agents may be de- 
manded. Diphtheria is one of the diseases in which it is easy 
to do too little, but also to kill the patient in the hurry and 
haste of fighting the disease. 

The treatment should be mainly preventive. In the light 
of the fact that the contagion of diphtheria need not be direct, 
but may be carried by persons who are not themselves taken, 
it will readily be seen how difficult it is to prevent, or to escape 
it. Herbert Peck reported (London Lancet, December 14, 1895) 
the case of house B, which was probably infected by the father 
of the family, who himself did not suffer from the disease. His 
son did not suffer, though there were germs in his throat, 'but 
he carried diphtheria to house C, whence it was taken to house 
D. This is only an instance of a large class. To what extent 
the bacilli and cocci in the mouths of healthy persons, where 
they are frequently found, may infect others, it is yet impossible 
to tell. That may depend on circumstances we have not yet 
much knowledge of. We know, for instance, that saliva is, to a 
certain extent, a disinfectant, but also that it is least so for the 
diphtheria bacillus (and the pneumococcus). It is also probable 
that a recent invasion is not so dangerous as older ones, which 
attain a higher degree of virulence when remaining some time 
in the crypts of the tonsils (E. Lexer, Arch. Tclin. Clair., 1897, 
vol. liv.). 

As a preventive measure* every individual case of diphtheria 

* See the New York Health Department's recommendations and rules 
on page 230. 



INFECTIOUS DISEASES. 255 

demands isolation, during the winter on the upper floor of 
the house, the windows should be open as much as possible, 
furniture of any kind reduced to the least possible quan- 
tity, the room changed every few days, and the bedding fre- 
quently. 

To what extent the infecting substance may cling to sur- 
roundings is best shown by the cases of diphtheria springing 
up in premises which had not seen diphtheria for a long time, 
but had not been interfered with; and best, perhaps, by a series 
of observations of auto-infection. When a diphtheritic case 
has been in a room for some time, the room, bedding, curtains, 
and carpets are infected. The child is getting better, has a new 
attack, may again improve, and is again stricken down. Thus 
1 have seen them die; but also improve immediately after hav- 
ing been removed from that room or that house. If barely pos- 
sible, a child with diphtheria ought to change its room and bed 
every few da} T s. 

The sick in crowded houses and quarters ought to be trans- 
ferred to a special hospital, which ought not to be too large. 
The Willard Parker Hospital, Xew York, with its sixty beds 
for scarlatina and diphtheria, is in that respect a praiseworthy 
example. The large amount of good it is doing would grow in 
geometrical progression if there were, as there ought to be in a 
large and ambitious metropolis, half a dozen institutions of the 
same class, not only in behalf of the poor, but of the well to do 
also, both townspeople and strangers. I have advocated, for 
dozens of years, the erection of a hospital for the accommoda- 
tion of infectious diseases breaking out among the thousands 
of strangers staying in Xew York City at all times. As long as 
there is no place to go to, the cases of scarlatina, diphtheria. 
etc., are hidden in, and are infecting, the boarding-houses and 
hotels, and the population at large. It is but two years now 
since a movement in favor of the establishment of such a hos- 
pital was begun. 

When diphtheria breaks out in a house, either private or 



256 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tenement, with no facility of isolation and.no hospital in which 
to seek refuge, the well should be removed to a healthy place; 
in large cities, temporary homes ought to be provided for 
that purpose, to benefit the children of the poor. If the 
rich would but remember that their children will be affected 
through the many links between them and the poor (servants, 
messengers, schools, dresses brought home from the tailor or 
seamstress, or purchased in the stylish and expensive establish- 
ments which give out the work to tenement working-people 
and sweat-shops), their very egotism should compel them to do 
in their own interest what humanity does not appear to sug- 
gest to them. The sick should be reported to the health boards 
at once. The well children of a family with diphtheria must not 
go to school or church before a fortnight — the possible period 
of incubation, which some extend to twenty days — has elapsed 
since their last contact with the sick. Schools must even be 
closed now and then, when an epidemic makes its appearance; 
teachers should know how to examine a throat. In this respect 
the regular inspection of schools by medical men, as introduced 
in New York, will prove an infinite blessing to the community. 
The condition of the house is to be examined into and im- 
proved; attendants, servants, nurses and cooks, seamstresses 
and laundresses, teachers, shopkeepers, restaurant-keepers, bar- 
bers, hair-dressers, with their mild diphtheritic attacks and 
strong pecuniary interests, are frequent sources of infection. 
In times of common danger, public places, theatres, ball-rooms, 
dining-halls, public vehicles, hackney-coaches, and railroad-cars 
should be examined by the authorities. There must be no 
clashing permitted between the public good and the individual 
money-bag. Clothing, bedding, room, and house should be 
thoroughly disinfected; articles used in the sick-room burned 
or soaked in a disinfecting fluid in the room, not carried over 
the house in a dry state; the rooms thoroughly disinfected 
after a case terminated favorably or unfavorably; the corpse 
disinfected, the funeral private, nothing removed from the 



INFECTIOUS DISEASES. 257 

house unless disinfected, no pieces of carpet thrown away to 
be picked up by beggars, no mattresses benevolently donated to 
the unsuspecting poor.* 

Prevention can accomplish a great deal for the individual. 
Diphtheria will, as a rule, not attack a healthy integument, be 

* To what extent contagion will prove dangerous the case reported to 
me by Dr. W. W. Ralston, of Horton, Kansas, may illustrate : . . . "The 
water used by the family is of the best quality, the drainage perfect, and 
the hygienic surroundings perfect, as far as I can make out. There has 
never been an undoubted case of diphtheria in the town, nor are there 
cases near here. The little fellow has not been away from home, nor 
have outsiders been at his home. 

"The case was at first tonsillitis, the result of exposure to cold. An 
abscess formed in one tonsil, and, after its rupture and discharge, the 
child had temporary relief. Up to this time there had been no par- 
ticular systemic disturbance other than the tonsillar trouble would 
account for, nor were the voice and breathing affected any different 
from what would be expected in this disease. A day or so before the 
abscess broke, his mother thought swabbing the throat with alum-water 
might give him relief, and she proceeded to do this, using a sponge- 
swab that she had used in swabbing the throat in a case of diphtheria 
in her family in Chicago two years ago. Two days after the use of 
this swab laryngeal stenosis began to show itself, together with a 
profound systemic disturbance characteristic of diphtheria, and death 
resulted in three or four days from septic absorption and obstruction 
to breathing. Before I saw him his mother had applied some liniment 
over the angle of jaw, which produced a blister. No change was ob- 
served on this blistered surface until about the time the laryngeal ste- 
nosis began to show itself, when a tough grayish membrane, closely 
adherent to the underlying surface and bleeding when detached, — 
which was done with difficulty, — showed itself. The urine showed by 
ordinary test about one-fourth albumin. I cannot account for the 
trouble in any other way than through the swab used. 

"The family moved from Chicago to Detroit, where they lived six 
months before coming here last February, carrying the swab with them 
on their travels. There can be no doubt but that the case in Chicago 
on which the swab was used was one of diphtheria. Diphtheria was 
epidemic in the part of the city in which they lived, and the diagnosis 
was made by an able physician. About one-third of those attacked 
in this epidemic died." . . . 

17 



258 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

this cutis or mucous membrane. The best preventive is, there- 
fore, to keep the mucous membrane in a healthy condition, as 
I have tried to practise and teach these forty years. Catarrh 
of the mouth, pharynx, and nose must be treated in time. 
Many a chronic nasal catarrh, with big glands round the neck, 
requires sometimes but two or three daily salt-water irriga- 
tions (1-130, warm) of the nose, and, if the children be large 
enough to do so, gargling. The addition of one per cent, of 
alum will often be found useful. This treatment, however, 
must be continued for many months, and may require years. 
Still, there is no hardship in it, and no excuse for its omission. 
A. Caille's many eloquent appeals have done much to popularize 
it. The nasal spray of a solution of nitrate of silver, 1-500 or 
1000, when there are erosions, will accelerate the cure. Its 
application must be repeated every other day for some time. 
Not infrequently has a treatment which was considered obso- 
lete when I was young been of great service to me. It consists 
in the internal administration of the tincture of pimpinella 
saxifraga. It is certainly an efficient remedy in subacute and 
chronic pharyngitis and laryngitis. I generally give it to 
adults, diluted with equal parts of glycerin and water, a tea- 
spoonful of the mixture every two or three hours, with the 
warning that no water must be taken soon after; children in 
proportion. 

Large tonsils should be resected and adenoid growths re- 
moved while there is no diphtheria. For during an epidemic 
every wound in the mouth is liable to become diphtheritic, and 
such operations ought to be postponed, if feasible. The scoop- 
ing out of the tonsils, for whatever cause, I have given up since 
I became better acquainted with the use, under cocaine, of the 
galvano-cautery. From one to four applications to each side 
(also to the post-nasal space) are usually sufficient for every case 
of enlarged tonsils or lacunar or deep-seated follicular amyg- 
dalitis ("tonsillitis"). It is advisable to cauterize but one side 
at a time, to avoid inconvenience in swallowing afterwards, and 



INFECTIOUS DISEASES. 259 

to burn from the surface inward. Cauterization of the centre of 
the tonsils may result in swelling, pain, and suppuration, unless 
the cautery is carried entirely to the surface; that means to 
say, the scurf must be on, or extend to, the surface, not remain 
inside the tissue. Another precaution is to apply the burner 
cold, press it on, and then heat. A strong hook, bent in a con- 
venient angle, introduced into a follicular fistula, and torn 
through the superjacent tissue, will also cause cicatrization and 
a cure. 

Nasal catarrh and proliferation of the mucous and sub- 
mucous tissue may require the same treatment, but in my ex- 
perience the cases which demand it are less frequent than those 
in which the tonsils need correction. 

The presence of glandular swellings round the neck should 
not be tolerated. They, and the oral and mucous membranes, 
affect each other mutually. Most of them could be prevented, 
if every eczema of the head and face, every stomatitis and 
rhinitis resulting from uncleanliness, injury, or whatever cause, 
were relieved at once. Painstaking care of that kind would 
prevent many a case of diphtheria, glandular suppuration, de- 
formity, or pulmonary consumption. 

For its salutary effect on the mucous membrane of the 
mouth, chlorate of potassium, or sodium, which is still claimed 
by some to be a specific in diphtheria, or almost so, is counted 
by me among the preventive remedies. If it be anything more, 
it is an adjuvant only. It exhibits its best effects in the ca- 
tarrhal and ulcerous condition of the oral cavity. In diphtheria 
it preserves the mucous membrane in a healthy condition, or re- 
stores it to health. Thus it prevents the diphtheritic process 
from spreading. 

Diphtheria is seldom observed on healthy, or apparently 
healthy, tissues. The pseudo-membrane is mostly surrounded 
by a sore, hyperasmic, cedematous mucous membrane, to which 
it will then extend. Indeed, this hyperemia precedes the ap- 
pearance of the diphtheritic exudation in almost every case. 



260 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

The exceptions to this rule are formed by those cases in which 
the virus may take root in the interstices, pointed out by 
Stoehr, between the normal tonsillar epithelia. Indeed, many 
cases of throat-disease occurring during the prevalence of an 
epidemic of diphtheria are but those of pharyngitis, which, 
under favorable circumstances only, develop into diphtheria. 
These throat-diseases are so very frequent during the reign of 
an epidemic, that in my first paper on diphtheria (Amer. Med. 
Times, August 11 and 18, 1860) I based my reasoning on two 
hundred cases of genuine diphtheria, and one hundred and 
eighty-five of pharyngitis without a visible membrane. 

These cases of pharyngitis, and those of stomatitis and phar- 
yngitis which accompany the presence of membranes, are bene- 
fited by the local and general effect of chlorate of potassium. 
When the surrounding parts are healthy or return to health, 
the pseudo-membrane remains circumscribed. The generally 
benign character of purely tonsillar diphtheria, which is apt to 
run its full course in from four to six days, has in this manner 
contributed to secure to chlorate of potassium the undeserved 
reputation of being a remedy, the remedy, in diphtheria. The 
dose of the salt must not be larger than fifteen grains (one 
gramme) for an infant a year old, not over twenty or thirty 
(1.5-2) for a child from three to five years, in the twenty-four 
hours. An adult should not take more than one and a half 
drachms (six grammes) daily. These amounts must not be 
given in a few large doses, but in repeated doses and at short 
intervals. A solution of one part in sixty will allow a teaspoon- 
ful every hour or half a teaspoonful every half -hour in the case 
of a baby one or two years old. 

It is not too late yet to raise a warning voice against the 
use of larger doses. Simple truths in practical medicine do 
more than simply bear repetition: they require it. For though 
the cases of actual chlorate of potassium poisoning are no 
longer isolated, and ought to be generally known, fatal acci- 
dents are still occurring even in the practice of physicians. 



INFECTIOUS DISEASES. 261 

When I experimented on myself, with half-ounce doses, forty- 
years ago, the results were 6ome gastric and intense renal irri- 
tation. The same were experienced by Fountain, of Daven- 
port, Iowa, whose death from an ounce (30.0) of the salt has 
been impressively described in Alfred Stille's "Materia Medica," 
from which I have quoted it in my "Treatise" on diphtheria. 
His death from chlorate of potassium induced me to prohibit 
large doses as early as 1860. In my contribution to Gerhardt's 
Handbuch der Kinderlcranklieiten, vol. ii., 18 7 7, I spoke of a 
series of cases known to me personally. In a paper read before 
the Medical Society of the State of New York in 1879 (Med. 
Record, March 15), I treated of the subject monographically, 
and alluded to the dangers attending the promiscuous use of 
the drug, which has descended into the ranks of domestic reme- 
dies; and finally, in my "Treatise" (Xew York, 1880), I col- 
lected all my cases and the few then recorded by others. Since 
that time the recorded cases have become quite numerous. The 
facts are undoubted, though the explanations may differ. The 
probability is that death occurs from methasmoglobinuria pro- 
duced by the presence of the poison in the blood, and consecu- 
tive nephritis, though Stockvis has tried, by a long series of 
experiments, to fortify my original assumption that the fatal 
issue was due to primary acute nephritis. 

There is, in every individual case, a certain danger, which, 
though it be common enough in other exhausting diseases, 
is of particular moment in diphtheria, where it is most fre- 
quent, even in apparently mild cases. It may be averted by 
meeting it early. It is heart-failure. "Where it has occurred, 
the indications for treatment become as clear as they are urgent 
but often futile. TThen it is simply feared, a preventive treat- 
ment will save many a case. 

Heart-failure is usually developed gradually. It is fore- 
shadowed by an increasing frequency and weakness of both 
heart-beats and pulse, by an occasional intermission, by un- 
equal frequency of the beats in a given period (say of ten 



262 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

seconds), or by the equalization of the interval between systole 
and diastole, and diastole and systole. This latter condition, 
which is normal in the embryo and fcetus, is always an ominous 
symptom; so is the too close proximity of the second sound (so 
as to become almost inaudible) to the first. 

Heart-failure is due, besides the influences common to every 
disease and every fever, to tissue changes in the myocardium, 
in the nerves, in the endocardium, and to the gradual forma- 
tion of blood-clots. These changes may be due to the ill- 
nutrition of the tissues resulting from every septic condition of 
the blood, or to specific alterations due to the diphtheritic pro- 
cess. Failure may either come on after having given warning, 
or it may be on you without any. Thus, every case of diph- 
theria ought to make us anxious and afraid. Indeed, there 
is no safety and no positive prognosis until the patient is quite 
recovered, and even advanced beyond the period in which 
paralysis may develop. 

Whatever enfeebles must be avoided; absolute rest must be 
enjoined. The patients must be in bed, without excitement of 
any kind; take their medicines — which ought to be as pala- 
table as possible — and their liquid food, and evacuate their 
bowels in a recumbent or semi-recumbent position; crying and 
worrying must be prevented; the room kept airy and rather 
dark, so as to encourage sleep if the patient be restless; and 
restless they are, unless they be under the influence of sepsis, 
and thereby subject to fatal drowsiness and sopor. In no dis- 
ease, except, perhaps, in pneumonia, have I seen more fatal 
results from exertion on the part of the sick, or from anything 
more fatiguing than a sudden change of posture. Unless abso- 
lute rest be enforced, neither physician nor nurse have dono 
their duty. The latter must avoid all the dangers attending the 
administration of medicines, injections, sprays, and washes. 
Preparations for the same must be made out of sight, every 
application should be made quickly and gently. On no account 
must a patient be taken out of bed for that purpose. I know of 



INFECTIOUS DISEASES. 263 

children dying between the knees of nurses who called them- 
selves trained and had a diploma. 

Pharmaceutical preparations, such as digitalis, strophanthus, 
sparteine, caffeine, besides camphor, alcohol, and musk, should 
not be postponed until feebleness and collapse have set in. 
These are at least possible, even probable; and this is certain, 
that a cardiac stimulant will do no harm. It is advisable to use 
it at an early date, particularly in those cases in which, perhaps, 
antipyrin or antifebrin — the indications for which are certainly 
rare, as excessive temperatures are very exceptional only — is 
given. Besides, it is not enough that the patients should 
merely escape death; they ought to get up, cito, tuto, et ju~ 
cunde, with little loss and speedy recuperation; a few grains of 
digitalis or their equivalent — preferably a good fluid extract — • 
may or should be given, in a pleasant and digestible form, 
daily. When a speedy effect is required, one or two doses of 
two or four minims each are not too large, and must be fol- 
lowed up by smaller ones. When it is justly feared lest the 
effect of digitalis be too slow, I give, with or without it, 
strophanthus, in doses of from one to six drops of the tincture, 
or sulphate of sparteine. Of the latter an infant a year old will 
take one-tenth or one-fourth of a grain (six to fifteen milli- 
grammes) four times a day as a matter of precaution, and every 
hour or two hours in an emergency. 

Of the same importance are alcoholic stimulants. The ad- 
vice to wait for positive symptoms of heart-failure and collapse 
before employing the life-saving apparatus is bad. There are 
cases which get well without treatment, but we do not know 
beforehand which they will be. No alleged mild case is safe 
until it has recovered. When heart -failure has once set in — 
and often will it occur in apparently mild cases — our efforts 
are too often in vain. Thus alcoholic stimulants ought to be 
given early and often, and in large quantities, thoroughly di- 
luted. There is no such thing as danger from them or intoxica- 
tion in septic diseases. A few ounces daily may suffice; but I 



264 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

have often seen ten ounces (300.0) daily of brandy or whiskey 
save children who had been doing badly with three or four 
(90.0-120.0). 

Caffeine, or, in its stead, coffee, is an excellent cardiac tonic, 
except in those cases in which the brain is suffering from an 
active congestion. For subcutaneous injections the salicylate 
(or benzoate) of caffeine and sodium, which readily dissolves 
in two parts of water, is invaluable for emergencies, in occa- 
sional doses of from one to five grains (six to thirty centi- 
grammes) in from two to ten minims of water. From five to 
twenty grains (0.3-1.25) of camphor may be given daily, as 
camphor-water, or in a mucilaginous emulsion, which is easily 
taken. It does not so disturb the stomach as carbonate of am- 
monium is apt to do. For rapid effect it may be administered 
hypodermically, in four or five parts of sweet almond oil, which 
is milder and more convenient than ether. Strychnine may be 
added regularly from the beginning of danger, and mainly in 
cases with little increase of temperature. Its effect is more 
than momentarily stimulating. A child of three years will take 
a one-hundredth of a grain (^ milligramme) three times a 
day, and more in an urgent case, and then subcutaneously. 
But the very best internal stimulant in very urgent cases is 
Siberian musk. I prefer to give it from a bottle, in which it 
is simply shaken up with a thin mucilage. In urgent cases it 
ought to be given in sufficient doses and at short intervals. 
When ten or fifteen grains administered to a child one or two 
years old within three or four hours will not restore the heart's 
action to a more satisfactory standard, the prognosis is very bad. 

The local treatment of the pseudo-membranes of the fauces is 
a subject of great importance. To still look upon them as an 
excretion which needs no interference, is incorrect. If it were 
possible to remove or destroy them, it would be a great comfort; 
but they can be reached only in certain places, and just in those 
in which they do least harm. Pseudo-membranes on the ton- 
sils are the least dangerous, for their lymph communication 



INFECTIOUS DISEASES. 265 

with the rest of the body is very scanty. Thus almost all forms 
of tonsillar diphtheria are among the most benign, at least as 
long as the process does not extend. Most cases of the kind 
run their mild course in from five to seven days, and it is just 
these which have given rise to the many proposals of tearing, 
scratching, cauterizing, swabbing, brushing, and burning. 
There are cases which do not show the harm done. But neither 
the galvano-cautery nor carbolic acid, nor tannin and glycerin, 
nor perchloride or subsulphate of iron can be applied with 
leisure and accuracy to the very membrane alone, except in the 
cases of very docile and very patient children. In almost every 
case the surrounding epithelium is getting scratched off or 
injured, and thus the diphtheritic deposit will spread. Besides, 
the membrane of the tonsil is altered surface tissue (it always 
is wherever the epithelium is pavement), and not deposited 
upon the mucous membranes, from which it might be easily 
detached, but embedded in the tissue. Whatever is done must 
be accomplished without violence of any kind. Nasal injec- 
tions or irrigations can be made so as to wash the posterior 
pharynx and the tonsils sufficiently, and thus render useless 
the special treatment directed exclusively to the throat. Be- 
sides, it is easier, meets with less objection, and gives rise to less 
exhaustion than the forcible opening of the mouth. This fact 
is of great importance, as I shall show in connection with the 
local treatment of the nasal cavity. Where it is possible to 
make local applications without difficulty, the membrane may 
be brushed with tincture of iodine several times daily, or a drop 
of rather concentrated carbolic acid. Of powders I know only 
one, the application of which is not contraindicated, — viz., 
calomel, perhaps also, iodol. Even this may irritate by its very 
form. Everything dry irritates and gives rise to cough or dis- 
comfort. Whatever has, besides, a bad taste or odor, such as 
sulphur, iodoform, or quinine, must be abhorred. Quidquid 
delirant medici pleduntur cegroti. Sugar has been recom- 
mended as a panacea, also table salt.(!) 



266 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

In bad cases of septic diphtheria applications of the tincture 
of the sesquichloride of iron have been highly recommended. 
The frequent doses of the tincture of chloride of iron intro- 
duced by me (see below) have the same, if no better, local effect. 
Loffler's solution of alcohol sixty, toluol thirty-six, and tincture 
of iron sesquichloride four parts is not preferable to many 
others. The injections into the tissue of the tonsils of carbolic 
acid or chlorine-water are objectionable in most cases, if it 
were only for the reason that they strike only the least danger- 
ous locality. 

The dioxide of hydrogen is a two-edged sword. It is cer- 
tainly a disinfectant, but in contact with mucous membranes 
it coagulates the soluble albumin of the tissue. More or less 
extensive discolorations and pseudo-membranous deposits were 
caused by it, which were quite often large enough to be mis- 
taken for diphtheritic. When they fell off there were sore sur- 
faces ready for another invasion of bacilli or cocci. Many such 
cases would get well only when the dioxide was stopped, and a 
simple local treatment with lime-water substituted. By some 
the injurious action was attributed to the presence in the drug 
of acid, while there have been those who claim the acidity to 
be the cause of its beneficial effect. 

For the purpose of dissolving membranes papayotin, or 
papain, has been employed. It is soluble in twenty parts of 
water, and may be injected, sprayed, or brushed on. I have 
used it in greater concentration, in two or four parts of water 
and glycerin, in the nose, throat, and, through the tracheotomy 
tube, in the trachea. One of the irrepressible drug manufac- 
turers and advertisers pushes the claims of a modification of the 
drug, which he calls papoid. For the same purpose trypsin is 
preferred by others. The mode of the application of papayotin 
is no indifferent matter. When applied in powder, it resulted 
in constant irritation of the throat, while the patient otherwise 
was convalescent. The pharyngeal hyperemia and slight exu- 
dation disappeared when mild alum washes were substituted. 



INFECTIOUS DISEASES. 267 

Diphtheria of the nose is apt to terminate fatally unless ener- 
getic local treatment is commenced at once. This consists in 
persevering disinfection and cleansing of the mucous surface. 
The disinfecting procedure must not be omitted long, because 
general sepsis results from rapid absorption through the sur- 
face, which is supplied with lymph-ducts and small superficial 
blood-vessels to an unusual extent. Disinfectant or merely 
cleansing injections must be continued every hour, for one or 
more days. If they be well made, the consecutive adenitis, par- 
ticularly that about the angles of the lower jaw, is soon re- 
lieved, and the general condition improved. But there are 
cases in which it is not the lymph-bodies that are the main 
gates through which constitutional poisoning takes place, but 
the blood-vessels only. In the incipient stage of such cases the 
discharge from the nostrils is more or less sanguineous; in 
them the blood-vessels, thin and fragile, carry the poison in- 
ward with great rapidity. 

In a few cases injections are unsuccessful. They are those 
in which the whole nasal cavity is filled with membranous de- 
posits to such an extent as to require forcible removal. Some- 
times it is difficult to push a silver probe through them. This 
procedure may be repeated, the probe dipped in carbolic acid, 
or wrapped in absorbent cotton moistened with carbolic acid 
of fifty or ninety per cent. After a while injections or irriga- 
tions alone will suffice. But now and then the development of 
pseudo-membranes is very rapid, a few hours suffice to block 
the nostrils again, and the difficulty is the same. 

The liquids which are to be injected should be warm and 
fairly mild. Solutions of chloride of sodium (6 : 1000); satu- 
rated solutions of boric acid; one part of bichloride of mercury, 
thirty-five of chloride of sodium, and five thousand of water, 
more or less; or pure lime-water; or solutions of papayotin, or 
a solution of hyposulphite of sodium, will be found satisfactory. 
From the selection of these remedies it is at once apparent that 
the object in view is partly that of washing out and dissolving, 



268 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

and partly of disinfecting. I have not mentioned carbolic acid, 
which may be used in solutions of one per cent, or less. Its 
employment requires care, for much of the injected fluid is 
swallowed, and proves a danger to children of any age, but 
mostly to the young. 

Most of the syringes I find in my rounds are abominations. 
The nozzle must be large, blunt, and soft. After having rec- 
ommended for many years the common hard-rubber ear- 
syringe, the sharp end of which was cut off, I now use always 
a short stout glass syringe with soft-rubber mounting in front. 

When the children cannot, or must not, be raised, I employ 
the same solutions from a nasal cup, a spoon, or a plain David- 
son atomizer, the nozzle being lengthened by a short piece of 
rubber tubing. These applications can thus be made while 
the children are lying down, every hour or very much oftener, 
without any or much annoyance. The nozzle should be large 
enough to fit the nostril. Sprays will never be so effective as 
injections or irrigations. 

For a day or two these injections of fluids or sprays must be 
made hourly. It is not cruel to wake the children out of their 
septic drowsiness; for it is certain death not to do so. 

Injections of the nose are oftener ordered than judiciously 
made. Hundreds of times have I been assured that they had 
been made regularly, hourly, for days in succession. Still there 
was a steady increase of glandular swelling and sepsis. I never 
believe a nurse to have made them regularly unless I have seen 
her doing it. They will run up their syringe vertically and 
not horizontally; the fluid will return through the same nostril. 
On the successful injecting or spraying of the nares hangs every 
life in a case of nasal diphtheria. I have long learned to look 
upon a neglect to tell at every visit how to make an injection, 
as a dereliction of duty. This may appear a trifling way, but 
it is a safe one. The nurse must be made to tell you that at 
every injection the fluid returns through the other nostril, or 
through the mouth, or that it is swallowed. 



INFECTIOUS DISEASES. 269 

The procedure is simple enough, and need not take more 
than half a minute for both nostrils. A towel is thrown over 
the child's chest up to the chin, and the child gently raised in 
bed by the person who is to make the injection. This person, 
sitting on the bed behind the patient, steadies the patient's head 
against her chest, while somebody else secures his hands. 
The syringe is introduced horizontally by the person sitting be- 
hind the patient, and gently emptied. No time must be lost 
in refilling and attending to the other side. There ought to be 
two syringes ready for use. When pain is complained of in the 
ears in spite of the utmost gentleness in injecting, — such cases 
will be found to be very exceptional, — more gentleness is re- 
quired, or the spray, or pouring in from a spoon, or minim- 
dropper even, or, better, from a nasal cup, has to take the place 
of the injection. 

Many sins are committed in doing this very simple thing. 
The unfortunate little one is made to see all the preparations, 
and is worried and excited, and the necessary gentleness in the 
proceedings is neglected in too many cases. 

For the purpose of softening and macerating pseudo-mem- 
branes steam has been utilized extensively. Its inhalation is 
useful in catarrh of the mucous membranes, and in many in- 
flammatory and diphtheritic affections. On mucous membranes 
it will increase the secretion and liquefy it, and thus aid in the 
throwing off of the pseudo-membranes. Its action is the more 
pronounced the greater the amount of muciparous follicles 
under or alongside a cylindrical or fimbriated epithelium. Thus 
it is that tracheo-bronchial diphtheria, so-called fibrinous bron- 
chitis, is greatly benefited by it. Children affected with it I 
have kept in small bath-rooms for days, turning on the hot 
water, and obliging the patient constantly to breathe the hot 
clouds. Several such cases I have seen recover with that treat- 
ment. Atomized cold water will never yield the same result. 
Nor have I seen the patented inhalers do much good. 

Still, where the surface epithelium is pavement rather than 



270 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

cylindrical, and but few muciparous follicles are present, and 
the pseudo-membrane is rather immerged in, and firmly co- 
herent with, the surface, — for instance, on the tonsils, — the 
steam treatment is less appropriate. On the contrary, moist 
heat is liable in such cases to favor the extension of the process 
by softening the hitherto healthy mucous membrane. Thus 
it takes all the tact of the practitioner to select the proper cases 
for the administration of steam, not to speak of the judgment 
which is required to determine to what extent the expulsion of 
air from the steam-moistened room or tent is permissible. 

Steam can be properly mixed with medicinal vapors. In the 
room of the patient water is kept boiling constantly over the 
fireplace, provided the steam is prevented from escaping di- 
rectly into the chimney, on a stove (the modern self-feeders 
are insufficient for that purpose and abominations for every 
reason); over an alcohol-lamp, if we cannot do better; not on 
gas, if possible, because of the large amount of oxygen which 
it consumes. Every hour a tablespoonful of oil of turpentine, 
and perhaps also a teaspoonful of carbolic acid, is poured on 
the water and evaporated. The air of the room is filled with 
steam and vapors, and thus the contact with the sore surfaces 
and the respiratory tract is obtained with absolute certainty. 

The secretion of the mucous membranes is sometimes quite 
abundant under the influence of steam, but still more, like that 
of the external integuments, increased by the introduction of 
water into the circulation. Therefore, drinking of large quan- 
tities of water, or water mixed with an alcoholic stimulant, 
must be encouraged. Over a thoroughly moistened mucous 
membrane the pseudo-membrane is more easily made to float 
and to macerate. 

To evolve large volumes of steam the slaking of lime has 
been resorted to. It is both an old and an effective procedure. 
Not only is the object in view accomplished by it, but it is the 
best means of bringing lime into contact with the morbid sur- 
face. In a room in which lime has been slaked, everything 



INFECTIOUS DISEASES. 271 

is getting covered with it. Thus this method of profiting by 
the local effect of lime is decidedly preferable to the almost 
nugatory effect of lime-water sprayed into the throat. 

It was to fulfil the same indication of softening the pseudo- 
membrane, by increasing the secretion of the mucous mem- 
branes, that pilocarpine or jaborandi was highly recommended 
(Guttmann) as a panacea in all forms of diphtheria. There is 
no doubt that the secretion of the mucous membranes is vastly 
increased by its internal application, and by repeated subcu- 
taneous injections of the muriate or nitrate of the alkaloid, but 
the heart is enfeebled by its use. I have seen but few cases in 
which I could continue the treatment for a sufficient time. In 
many I had to stop it because after some days of persistent ad- 
ministration I feared for the safety of the patients. Therefore, 
as early as the meeting of the American Medical Association at 
Richmond, in 1880, I felt obliged to warn against its indis- 
criminate use in diphtheria. Thus it has shared the fate of all 
the hundreds of remedies and methods which have been de- 
clared to be infallible, and found wanting. 

Diphtheritic adenitis, the swelling of the cervical glands near 
the angles of the lower jaw, to which I have alluded as an 
ominous symptom, points to nasal and naso-pharyngeal (mostly 
mixed) infection. The main treatment consists in disinfection 
of the absorbing surfaces. 

Direct local treatment of the glands, if not entirely useless, 
is, at all events, of minor importance and efficiency. The ap- 
plication of an ice-bag of moderate size will render fair ser- 
vice. The use of one part of carbolic acid in ten of alcohol 
irritates both surface and patient more than it can do good. 
Inunctions may do some good by friction (massage) ; inunctions 
with some absorbable material in them may do a little better. 
The common iodide of potassium ointment is useless; iodide 
of potassium in three or five parts of glycerin is more readily 
absorbed; the same in equal parts of water, with a little animal 
fat, and six or eight times its quantity of lanolin, gives an 



272 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

ointment which is so rapidly absorbed that iodine is found in 
the urine within a few hours. Iodoform may be utilized in the 
same way. Injections of iodoform in ether, which I suggested 
years ago, are too painful. Mercurial inunctions, those of blue 
ointment, require too much time for any effect to take place. 
Oleates are too irritating locally; a lanolin ointment would 
prove more satisfactory in doing less harm. After all, however, 
the readiest method of reducing the swelling of the glands, 
and improving the prognosis accordingly, is that of cleansing 
and disinfecting the field of absorption. The rare cases of sup- 
puration in these glands require incision and disinfection. 
They are as ominous as they are rare, however. There is but 
little pus, as a rule, but one or many local deposits of disin- 
tegrated gland-cells and gangrenous connective tissue. The 
incisions must be extensive, the scoop and concentrated carbolic 
acid should be freely used. In these cases hemorrhages may 
occur, some of them very difficult to manage. I have seen some 
of them terminate fatally. In these carbolic acid must be 
avoided. Compression, actual cautery, and acupressure have 
rendered good service. Solutions of iron must be avoided, for 
the scurf formed is a shield, behind which deleterious absorp- 
tion is going on constantly in such wounds, as it does in the 
uterus. Antipyrin in water (1 : 5-2) is an excellent styptic. 

The internal treatment of an average case of pharyngeal diph- 
theria can be made to combine the indications of both internal 
and local administration. For forty years I have employed 
the tincture of the chloride of iron. It is an astringent and 
antiseptic. Its contact with the diseased surface is as impor- 
tant as is its general effect; therefore it must be given fre- 
quently, in hourly or half-hourly doses, even every twenty or 
fifteen minutes. An infant of a year may take three or four 
grammes (one drachm) a day, a child of three or five years eight 
or twelve grammes (two or three drachms). It is mixed with 
water to such an extent that the dose is half a teaspoonful or a 
teaspoonful; a drachm, or two drachms, with a small quantity 



INFECTIOUS DISEASES. 273 

of chlorate of potassium (see above), in four ounces, allows 
half a teaspoonful every twenty minutes. No water must be 
drunk after the medicine. As a rule, it is well tolerated. There 
are some, however, who will not bear it well. Vomiting or 
diarrhoea is a contraindication to persevering in its use, for 
nothing must be allowed to occur which reduces strength and 
vigor. A good adjuvant is glycerin, a better one than syrups. 
From ten to fifteen per cent, of the mixture may consist of it. 
Now and then, but rarely, it is not well tolerated. When diar- 
rhoea sets in glycerin should be discontinued. Still, these cases 
are rare; indeed, the stomach bears glycerin very much better 
than the rectum. 

In connection with this remedy, I wish to make a remark 
of decidedly practical importance. I know quite well that re- 
covery does not always prove the efficacy of the remedy or 
remedies administered. But I have seen so many bad cases 
recover with chloride of iron, when treated after the method 
detailed above, that I cannot rescind former expressions of my 
belief in its value. Still, I have often been so situated that I 
had to give it up in peculiar cases. They were those in which 
the main symptoms were of so intense a sepsis, that the iron 
and other rational treatment were not powerful enough to pre- 
vent the rapid progress of the disease. Children with naso- 
pharyngeal diphtheria, large glandular swelling, feeble heart, 
and frequent pulse, thorough sepsis, and irritable stomach be- 
sides, those in which large doses only of stimulants, general and 
cardiac, may possibly promise any relief, are better off without 
the iron. When the circumstances are such as to leave the 
choice between iron and alcohol, it is best to omit the iron 
and rely on alcoholic stimulants mostly. The quantities re- 
quired are so large that the absorbent powers of the stomach 
are no longer sufficient for both. 

Nor is iron sufficient or safe in those cases which are pre- 
eminently laryngeal. To rely on iron in membranous croup 
means waste and danger. 

18 



274 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

In this latter form of membranous croup, diphtheritic laryn- 
gitis, or laryngeal, also in general (pharyngeal and nasal), diph- 
theria, the most useful internal remedy is mercury. Empiri- 
cism has often praised calomel in small and large doses. My 
acquaintance with mercury in this connection is not at all new. 
Many years ago I published (Med. Record, May 24, 1884) a 
number of cases which got well under its use; at the same time 
that Dr. Thallon, of Brooklyn, published an article on the same 
subject. Since I have employed it (I prefer the bichloride), 
my conviction of the utter uselessness of internal medication 
in laryngeal diphtheria, so-called pseudo-membranous croup, 
is thoroughly shaken. Until about that time I felt certain of 
a mortality of ninety or ninety-five per cent, of all the cases "of 
laryngeal diphtheria not operated upon. These figures were 
not taken from small numbers, for I compared those of others 
with my own. The latter are not a few, either; for within 
thirty years (until about 1890) I have tracheotomized more 
than six hundred times, have assisted at as many more opera- 
tions, and have seen at least one thousand cases of laryngeal 
diphtheria which were not operated upon at all. During the 
years from 1883 to 1890 I have seen no less than two hundred 
cases, perhaps many more. Among them recoveries have not 
been rare at all, at all ages, from four months upward. The uni- 
form internal medication consisted in the administration of a 
dose of the bichloride every hour. The smallest daily dose 
ever given by me in the beginning was fifteen milligrammes, 
one-fourth of a grain, to a baby of four months; this was con- 
tinued a few days, and the dose then somewhat diminished. 
Half a grain (0.03) daily may be given to children of from three 
to five years, for four or eight days or longer. The doses vary 
from one-sixtieth to one-thirtieth (0.001-0.002). They require 
a dilution of one in six thousand or ten thousand of water or of 
whiskey and water. There is no stomatitis, gastric or intestinal 
irritation is very rare. It occurred in a few cases, but then it 
was found that the dilution had not been sufficient, one in two 



INFECTIOUS DISEASES. 275 

thousand or three thousand only. If ever it exist, very small 
doses of opium will remedy it. 

The benefit to be derived from the remedy depends greatly 
upon the time of its administration. Tracheotomy or intuba- 
tion is required, as a rule, after days only, and can often be 
avoided if mercury be given in time. If the operation becomes 
necessary after all, the treatment must be continued diligently. 
Never have I seen so many cases of tracheotomy getting well, 
since 1863, as when the bichloride was being used constantly, 
since 1882. Nor am I alone with these favorable results. There 
are dozens of practitioners in New York City with whose 
methods and results I am well acquainted, some of whom are 
connected with me, in some capacity or other, who confirm the 
above statements. 

My experience with the bichloride is mainly gathered in 
cases of laryngeal and bronchial diphtheria, so-called pseudo- 
membranous croup and fibrinous bronchitis; it is there that 
it has been particularly effective. Still, but few of these were 
quite localized affections. Our cases of diphtheritic laryngitis 
are mostly descending, and complicated with either diphtheritic 
pharyngitis, rhinitis, or both. Not a few, mainly of the latter 
kind, exhibit constitutional symptoms of sepsis. Many such 
have also recovered. 

Another method of using mercury is that of sublimating 
calomel to be inhaled from time to time. It is particularly 
adapted to pseudo-membranous laryngitis. 

In any case of diphtheria there may occur conditions and 
complications which yield their own indications, and require 
the closest attention on the part of tne practitioner. I need 
not here refer again to the frequent attacks of exhaustion and 
heart-failure, which carry off a multitude of patients, unless 
they be met in time. What I said on previous pages on heart- 
failure and its prevention (or treatment) holds good in diph- 
theria, if anywhere. Therapeutical nihilism destroys as many 
lives as any number of direct mistakes in dosing. 



276 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Nephritis, parenchymatous, interstitial and glomerular, and 
the varieties of pneumonia are frequent complications or con- 
sequences of diphtheria. The treatment of either of them re- 
quires no particular recognition in this place. Nor does oedema 
of the glottis yield indications differing from that occurring 
from other causes. Diphtheria of the skin and of the sexual 
organs requires disinfectant ointments. I have mostly relied 
on iodoform one part, in from eight to twelve of fat. 

Diphtheritic paralysis, though of various anatomical and 
histological origin, yields in all cases a certain number of iden- 
tical therapeutical indications. These are: the sustaining of 
the strength of the heart by digitalis and other cardiac tonics. 
A child of three years may take daily, for a month, three grains 
(0.2) or its equivalent; for instance, one grain (0.06) of the 
extract. This is an indication on which I cannot dwell too 
much. Many of the acute, and most of the chronic, diseases 
of all ages do very much better by adding to other medications 
a regular dose of a cardiac tonic. While it is a good practice 
to follow the golden rule to prescribe simply, and, if possible, a 
single remedy only, it is a better one to prescribe efficiently. 

Besides, there are some more indications: mild preparations 
of iron, provided the digestive organs are not interfered with; 
strychnine, or other preparations of nux, at all events. In ordi- 
nary cases a child of three years will take an eightieth of a 
grain three or four times a day (together 0.002). Local friction, 
massage of the throat, of the extremities, and trunk, dry or 
with hot water or oil, or water and alcohol; and the use of both 
the interrupted and continuous currents, according to the 
known rules and the locality of the suffering parts, find their 
ready indications. The paralysis of the respiratory muscles is 
quite dangerous; the apncea resulting from it may prove fatal 
in a short time. In such cases the electrical current used for 
very short periods, but very frequently, and hypodermic in- 
jections of sulphate of strychnine in more than text-book doses, 
and frequently repeated, will render good service. I remember 



INFECTIOUS DISEASES. 277 

a case in which these, and the occasional use of an interrupted 
current, and occasional artificial respiration by Silvester's 
method, persevered in for the better part of three days, proved 
effective. In a few cases of diphtheritic paralysis the use of 
antitoxin appeared to score a success. Other forms of paralysis 
(hemiplegia, ataxia) demand a treatment like the above, modi- 
fied by their peculiar circumstances or symptoms. 

In regard to antitoxin, there are but few opposing voices left. 
Not quite so efficacious as thyreoid in myxcedema, it is more 
beneficial in its total usefulness because of the vast number of 
cases benefited by it. There is no practitioner but has at present 
the right — or rather the duty — to give it a place among his 
most reliable remedies. It is a pity that many of us, on 
account of distance, or other reasons for its inaccessibility, 
should be deprived of its services and compelled to rely exclu- 
sively on the treatment detailed above. There are in the worst 
forms of diphtheria so many urgent indications every one of 
which should be fulfilled, that the antidote of the circulating 
poison, if not on hand, will be sorely missed. For such a 
specific antidote it is, though it has not the power to cure 
every case of diphtheria any more than quinine cures every case 
of malaria or mercury of syphilis. Not counting isolated cases 
spread over the journals, the three hundred of Heubner's, five 
hundred of Baginsky's, thousand of Roux's, and the many 
hundreds of the hospitals of Paris and Vienna, besides those of 
our own country, yield a basis on which to establish calcula- 
tions. All observers agree on this point, that the sooner the 
antitoxin is injected the more certain is its effect. Some go so 
far as to assert that no case injected the first day need die. Dr. 
Henry Koplik, however, tells me that in cases complicated with 
pneumonia it acts badly. 

The doses to be administered are, according to Behring, as 
follows: according to the severity of a case, six hundred, one 
thousand, or fifteen hundred "antitoxin units" should be in- 
jected in a part of the body which contains loose subcutaneous 



278 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tissue and is not exposed to pressure. This dose may be re- 
peated if the symptoms are not improved within a day. A 
"unit" is equivalent to one cubic centimetre of what is called 
"normal serum." Normal serum is the blood-serum of an im- 
munized animal, which has been made so efficacious that one- 
tenth of a cubic centimetre will antagonize ten times the mini- 
mum of diphtheria virus fatal to a guinea-pig weighing three 
hundred grammes (ten ounces). 

It appears to be a fact acknowledged by all that there is 
rarely, if ever, an immediate bad result of the injection, which 
ought to be made into the subcutaneous tissue, not into the 
muscles. The point of injection should then be covered with 
an antiseptic gauze, or with iodoform collodion. Not, infre- 
quently, however, there is redness, erythema, or urticaria 
around the point of injection. Besides, some of the after- 
effects are liable to be very severe. Urticaria, polymorphous 
eruptions, petechise and suggillations, excessive perspiration, 
swelling of glands, severe pain and swelling in feet and limbs 
and joints, pruritus recti, severe diarrhoea and vomiting, nose- 
bleeding, and great debility have lasted for weeks, yet termi- 
nated in recovery. Dr. Rauschenbusch observed on his four- 
year-old daughter, who took three times the dose while sick 
with diphtheria two years previously, pruritus, urticaria, vomit- 
ing, sopor, heart-failure, after two hundred units injected for 
the purpose of immunization (Berl. hlin. Woch., 1897, No. 32). 
A few sudden deaths have also been reported. No connection 
between them and the antitoxin has been established in any 
case, and venturesome generalizing speculations are not able to 
shed light on obscure subjects. 

Dr. James Ewing* studied the effect of antitoxin on the 
number and nature of leucocytes. While leucocytosis begins 
a few hours after the invasion of diphtheria, and increases, 
mainly as regards myelocytes (one nucleus, neutrophile granu- 

* New York Medical Journal, August 17, 1895. 



INFECTIOUS DISEASES. 279 

lations, never found in the lymph-nodes), up to the climax of 
the disease and steadily declines during convalescence, — re- 
maining high only in most of the bad and fatal cases, — anti- 
toxin, according to Ewing, within thirty minutes after its in- 
jection, causes a reduction of the number of leucocytes. This 
reduction affects specially the uninuclear leucocytes, while the 
proportion of well-stained multinuclear cells is increased. In 
favorable cases, after the injection of antitoxin the leucocytosis 
never again reaches its original height. In severe and less 
favorable cases the injection is followed in a few hours by more 
hyperleucocytosis and fever. In very bad cases the immediate 
result may be either rapid increase or decrease of leucocytes, 
and death. The multinuclear leucocytes found in the blood of 
favorable cases after treatment with antitoxin show increased 
affinity for gentian violet. This change may be observed within 
twelve hours after the injection, and its non-occurrence is a 
very unfavorable prognostic sign. 

The existence of the after-effects mentioned above is not 
denied by any of the most enthusiastic admirers of antitoxin, 
but it is claimed that no serious or lasting results follow, and 
that if every life threatened by diphtheria were known to be 
protected by enduring the untoward effects of the remedy, we 
should willingly submit to them in every case. The balance 
of what we know of antitoxin is thus far favorable, and this 
addition to our therapeutical powers will forever be remem- 
bered as creditable to Emil Behring. The lack of recognition, 
which was some time ago withheld from him by many, was, 
most unfortunately, his own fault. The morbid vanity and 
some personal motives displayed in almost every one of his 
writings tallied so badly with the tendencies and spirit of a 
scientific benefactor as to render suspicious both his veracity 
and his motives. It is, therefore, a pleasure to notice greater 
circumspection and moderation in his later papers and dis- 
cussions. Still, it is a pity he is no clinician. If he were he 
would not have been tempted to assert that organotherapy has 



280 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

accomplished nothing, that cellular pathology has proved 
sterile, that remedies combat main symptoms only, that medi- 
cine hitherto had therapeutical principles only but no thera- 
peutical experiments, and that (his) experimental therapeutics 
is in conscious opposition to medication (German Congress of 
Int. Med., June, 1897). 

Altogether, the effects of antitoxin injections are eminently 
favorable. The fever of diphtheria is much lessened within or 
after a day, and the second fever-wave — so common between 
the third and the fifth day — is not often observed. The mem- 
brane is speedily disintegrated and disappears on the sixth day 
or sooner, while in cases not injected with antitoxin it lasts 
eight days or longer. Besides, there are but few cases on record 
in which the membrane returned after antitoxin, and not many 
in which it grew in size. In 181 cases of Heubner's there were 
but three relapses. Albuminuria and nephritis are common 
occurrences in diphtheria as early as the (second and) third 
day. Among those 181 cases of Heubner's, of those injected 
on the first day, five-sixths remained free; on the second, two- 
thirds; on the third, one-half; on the fourth, one-third. The 
results of Baginsky, Roux, and Widerhofer are similar. In 
525 cases of Baginsky's treated with antitoxin there was al- 
buminuria in 40.95 per cent., clinical nephritis in 12.57 per 
cent., and post-mortem nephritis in 15.80 per cent. However, 
among 933 cases treated without antitoxin there was albu- 
minuria in 42 per cent., clinical nephritis in 25.78 per cent., 
and post-mortem nephritis in 16.31 per cent., — rather a favor- 
able showing for antitoxin. In his 525 cases, heart-failure was 
noticed as the cause of death in eight; it occurred in 5.69 per 
cent, of all the cases, while it took place in 10.9 per cent, of the 
933 treated without serum, from 1891 to 1894. In Heubner's 
practice it occurred nine times, but was not fatal. 

It is claimed that whenever antitoxin is injected before 
laryngeal stenosis has developed, the larynx will remain free. 
It is certain that both tracheotomies and intubations have be- 



INFECTIOUS DISEASES. 281 

come less in number. In Baginsky's hospital service there 
were, between the years 1890 and 1894, 1258 cases of diph- 
theria; 418 tracheotomies and 135 intubations were performed, 
with a total mortality in these 553 operations of 62 per cent. 
In the 418 tracheotomies the mortality was 64.4 per cent.; 
among these were 77 which were performed after intubation; 
these 77 had a mortality of 69 per cent.; 58 intubations with- 
out secondary tracheotomy had a mortality of 41.8 per cent. 
This condition of things changed with the period of antitoxin 
treatment. No case of laryngeal stenosis developed in those in 
whom the remedy had been injected before the larynx became 
affected. Thus, in 525 cases there were but 53 tracheotomies 
and 54 intubations, the former with 34 deaths, the latter with 
2. It became necessary to perform tracheotomy after a pre- 
vious intubation in 12 cases; of these, 9 died. The speedier 
disintegration of the membranes and the (almost general) dis- 
continuance of their growth after the injection of antitoxin are 
the reasons why Baginsky prefers at the present time, in the 
injected cases, intubation to tracheotomy. 

Other observers arrive at similar results. Heubner had 33 
operations in 181 cases, — viz., 23 tracheotomies with 52 per 
cent., 10 intubations with 80 per cent, recoveries. 

Paralysis is no less frequent in antitoxin cases than it was 
formerly. But we must not lose sight of the fact that it never 
was exclusively found in very bad cases, but quite often after 
mild ones. Perhaps it results more from a mild but protracted 
poisoning than from a sudden and severe one. It may be, also, 
that many cases which survive with antitoxin and develop 
paralysis would not have lived to become paralyzed under a less 
satisfactory treatment. 

The principal question, however, to be raised in reference 
to any medication in cases of serious disease is its life-saving 
power. In its issue of August 8, 1895, the Deutsche medi- 
cinische WocJienschrift published a preliminary result of its col- 
lective investigation of antitoxin treatment. The report refers 



282 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

to 10,312 cases of diphtheria treated in the city of Berlin and 
outside: total mortality, 11.8 per cent. Of that number, 4479 
were treated without antitoxin and 5833 with it. Of all the 
patients, 1233 were below two years, with a mortality of 29 per 
cent.; 6740 from two to ten years, with a mortality of 11.4 
per cent.; 2339 over ten years, with a mortality of 3.9 per cent. 

Of the 4479 treated without antitoxin (mortality 14.7 per 
cent.), 498 were below two years, with a mortality of 39.7 per 
cent.; 2710 from two to ten years, with a mortality of 15 per 
cent.; 1271 over ten years, with a mortality of 3.7 per cent. 

Of the 5833 treated with antitoxin, 735 were below two years, 
with a mortality of 21.8 per cent.; 4030 from two to ten years, 
with a mortality of 8.8 per cent.; 1068 over ten years, with a 
mortality of 4.1 per cent. 

On the first and second days antitoxin was injected in 401 
cases of less than two years, with a mortality of 11.8 per cent.; 
2256 cases of from two to ten years, with a mortality of 4 per 
cent.; 696 cases of over ten years, with a mortality of 1 per 
cent.; total, 3353 cases, with an average mortality of 4.2 per 
cent. 

On the third day and later antitoxin was injected in 334 
cases of less than two years, with a mortality of 34.4 per cent.; 
1774 cases of from two to ten years, with a mortality of 14.9 
per cent.; 372 cases of over ten years, with a mortality of 9.9 
per cent.; total, 2480 cases, with an average mortality of 16.9 
per cent. 

Among the antitoxin cases there were 1018 of diphtheritic 
croup, of which 701 were treated without tracheotomy, with 
a mortality of 17.9 per cent.; 317 with tracheotomy, with a 
mortality of 33.1 per cent. These figures show, undoubtedly, 
that only the very urgent and most severe cases were subjected 
to the operation. Of all the cases of laryngeal stenosis, there 
were, below two years, without tracheotomy, 130, with a mor- 
tality of 29.3 per cent.; below two years, with tracheotomy, 49, 
with a mortality of 49 per cent.; from two to ten years, without 



INFECTIOUS DISEASES. 283 

tracheotomy, 484, with a mortality of 15.9 per cent.; from two 
to ten years, with tracheotomy, 250, with a mortality of 30 per 
cent.; over ten years, without tracheotomy, 87, with a mortality 
of 12.7 per cent.; over ten years, with tracheotomy, 18, with a 
mortality of 38.8 per cent. 

Not the least interesting statements refer to the quantities 
of antitoxin employed. In 3497 cases, 600 antitoxin units, or 
less, were used in 497 cases under two years, with a mortality 
of 16.1 per cent.; 2370 cases from two to ten years, with a 
mortality of 5.3 per cent.; 630 cases over ten years, with a mor- 
tality of 1.8 per cent.; the average mortality being 6 per cent. 

In 2336 cases, up to 1000 antitoxin units were used, of 
which 238 cases were under two years, with a mortality of 33.6 
per cent.; 1660 cases were from two to ten years, with a mor- 
tality of 13.8 per cent.; 438 cases were over ten years, with a 
mortality of 7.5 per cent.; the average mortality being 14.6 
per cent. 

These figures show that the milder cases, in which 600 units 
were considered enough, did best; that those which from the 
beginning offered a worse prognosis were given more antitoxin 
and did not behave so well. That means, among other things, 
that mild cases do better under any treatment than severe ones, 
in proportion. It also proves the necessity of not relying, im- 
plicitly, on a single method of treatment exclusively. 

Among the most enthusiastic eulogizers of antitoxin there is 
none but admits failures. Many of these are attributed to an 
insufficient strength of the serum. Mere serum of an immune 
animal does not suffice. Others — and these are the most con- 
clusive — depend on the insufficient power of resistance on the 
part of the patient. Thus the antitoxin injection alone should 
not be relied on. Nutrition and alcoholic and other medicinal 
stimulation must be resorted to. In regard to other treatment 
the authorities differ. Some, like Escherich, Baginsky, and 
Roux, favor it, Escherich particularly after the membranes 
have fallen off. Heubner rejects it. At all events, there are 



284 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

but few left who maltreat both the throat and the child by the 
former cruel methods of local applications and cauterizations. 
It should not be overlooked that the antitoxin does not destroy 
bacilli, which continue the evolution of toxin persistently. 
I have advised, whenever I had an opportunity, the combina- 
tion of my mercurial treatment with the antitoxin, for the 
reports on the efficacy of mercurial treatment as recommended 
by me (p. 274) are becoming more and more favorable. Ben- 
ney's Australian results and reports are very conclusive.* 
Some New York friends, to whom I offered antitoxin, declined 
it, declaring themselves fully satisfied with the results they 
obtained from mercury and intubation. On the other hand, a 
towns-fellow of ours who handles antitoxin a good deal pro- 
nounces mercury and antitoxin to be incompatible, and believes 
that mercury will interfere with the effect of antitoxin. This 
assertion has not been proved, but shows the facility with which 
postulates may be substituted for experience during a period 
of enthusiasm. No greater eulogy, both on mercury and on 
antitoxin, can ever be pronounced than the figures detailed by 
Dillon Brown and referred to below. 

These results tally perfectly with the very exhaustive report 
of the hospitals of the London Metropolitan Asylums Board 
(London Lancet, June 5, 1897), which, for the year 1896, proves 
a great reduction in the mortality of cases brought under treat- 
ment on the first three days of illness, the lowering of the com- 
bined general mortality to a point below that of any former 
year, the still more remarkable reduction in the mortality of 
the laryngeal cases, the uniform improvement in the results of 
tracheotomy, and finally the beneficial effect produced on the 
clinical course of the disease (N. Y. Med. Rec, September 4). 

Additional statistics concerning the effect of antitoxin are 
too numerous to be reported here. The collective investigation 
of the American Pediatric Society of 1895, the results of the 

* Australian Medical Journal, January 20, 1895. 



INFECTIOUS DISEASES. 285 

Boston City Hospital, and of endless other institutions, and 
those of painstaking practitioners all over the world, are unani- 
mous in regard to its efficiency, and to the lowered mortality 
following its use. The doses are, however, larger than those 
employed at first. 

So far as immunization through small doses of antitoxin is 
concerned, it appears to have been accomplished, in the opinion 
of many; but they all agree that it does not last long. Those 
who know that diphtheria, once induced, predisposes rather 
than protects will have no particular confidence in the effect of 
antitoxin as an immunizer; but if it saves the lives of many 
who are stricken, its sphere of usefulness will be indeed exten- 
sive. The collective investigation of the American Pediatric 
Society (Montreal session of May, 189G), which extends over 
many thousands of cases, is equally favorable. 

20. Rheumatism. 

Acute articular rheumatism is a frequent disease both in in- 
fancy and childhood. 

Since I made this statement twenty-two years ago,* after ob- 
servations extending over more than twenty years, a few au- 
thors accepted and verified it. But the majority are still of the 
opinion, inherited from their predecessors, that infancy and 
childhood are immune or almost so. Thus it is only a dozen 
years ago that Edlefsen reported to the German Congress for 
Internal Medicine (Transactions, 1885, p. 323) but eleven cases 
of acute rheumatism under five years, none of which was 
younger than two. The assertion that the disease is rare under 
four or under two ) r ears is frequently met with. 

Nothing can be more erroneous. The frequency of valvular 
diseases, mainly of the left side of the heart, in children of 

* A. Jacobi, "Acute Rheumatism in Infancy and Childhood," 1875, in 
a series of American clinical lectures., edited by E. C. Seguin, M.D., vol. 
i. No. 2. 



286 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

from four or five years to adolescence ought to suggest the fre- 
quency of rheumatism; for only few of them are due to scarla- 
tina, almost all are secondary to rheumatism, than which there 
is no more frequent cause of cardiac disorder. They cannot be 
claimed as congenital, for the fact that very few of the foetal 
diseases of the heart are found on the left side, and but a small 
number survive the first (or perhaps second) year, remains un- 
disturbed. Nor is the number of rheumatic cases limited to 
those exhibiting cardiac symptoms; for though endocarditis 
is of more frequent occurrence — compared with the number of 
cases — in the rheumatism of children than it is observed in 
adults (in whom from ten to twenty per cent, contract a perma- 
nent organic lesion of the heart), still there must be, and are, 
many cases of acute rheumatism which run their full course 
without terminating in heart-disease. In order to ascertain 
this, the heart is to be watched in every doubtful case. Endo- 
carditis is sometimes the first symptom of acute rheumatism in 
children, and precedes every other even in apparently mild 
cases, and pericarditis and myocardial changes are not rare. 
When the slightest symptom of chorea minor shows itself, the 
heart should also be examined together with the joints, for 
there are those cases in which chorea is not the final develop- 
ment of rheumatism and rheumatic endocarditis, but the very 
beginning of the disease, and then referable to a rheumatic 
affection of the spinal membranes, or of the heart-muscle. 

All of these remarks I believe to be opportune, because of 
the frequency of cases in which the persistent notion that rheu- 
matism is a rare disease gives rise to an erroneous diagnosis — 
the ubiquitous "dentition," "worms," "malaria," and "colds" — 
and to false treatment. After all, a correct diagnosis is the 
foundation and sine qua non of sound therapeutics; thus I shall, 
in this neglected instance, add a few words on the subject of 
diagnosis, which is sometimes quite difficult. 

Fever is a common symptom in small children; every physi- 
cal disturbance raises their temperature. In acute rheumatism 



INFECTIOUS DISEASES. 287 

it is often but slightly elevated; it sometimes rises at irregular 
times, being now and then highest about noon. The swelling 
of the joints is apt to be very trifling and is often overlooked, 
the pain (either spontaneous or on pressure) may be very much 
less than that resulting from fatigue, rhachitis, syphilitic bone- 
disease, colic, or otitis. Thus in every doubtful case of discom- 
fort or pain the joints and heart should be examined for rheu- 
matism. The diagnosis of acute articular rheumatism becomes 
quite difficult when but a single joint is affected, either tem- 
porarily or through the whole course of the attack, for a uni- 
lateral arthritis is very apt to be tuberculous or traumatic. 
Still, rheumatic monarthritis is observed principally in the 
hip- or knee-joint. Sometimes, after a week only or still later, 
the additional inflammation of other joints facilitates the rec- 
ognition of the exact condition. Isolated inflammatory rheu- 
matism fails also often to be recognized because of its being 
denominated "growing pain." The latter term dates from the 
medical nomenclature of past centuries, and ought to have been 
dropped long ago. What has been called by that name is of 
variable origin and nature. Sometimes it is fatigue only. It 
may be neurosis of a joint with or without an cedematous swell- 
ing. I have seen a number of such instances in children of 
both sexes, about the shoulder-, hip-, and knee-joint mostly. 
Another affection which has been classed under the head of 
"growing pain' 3 is rhachitical or other epiphysitis and the con- 
gestive swelling of the intermediate cartilage of the long bones. 
It is a frequent occurrence, without a perceptible cause besides 
the physiological hyperemia which is required for normal 
growth, and liable to become pathological; it is often noticed in 
the convalescence, or recovery, from infectious diseases, particu- 
larly scarlatina. Still, the large majority of attacks of "grow- 
ing pain" mean rheumatism; it is the failure to appreciate this 
fact that gives rise constantly to mistakes in diagnosis, and the 
neglect in the administration of both preventive and curative 
measures. 



288 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Eheumatism of the cervical column is apt to be very painful 
and attended with high fever, stiffness of the neck, retracted 
head, delirium, and sometimes vomiting. Some of these symp- 
toms are those of cerebral meningitis, and errors in diagnosis 
are easily made. 

There is no uniform cause or character of rheumatism. 
Staphylococcus aureus and pyogenous streptococci, mainly 
streptococcus citreus and diplococcus, have been met with. 
Does that mean that one or all of them are the origin and foun- 
tain of rheumatism, and that perhaps the latter is the result of 
many different infections by pyogenous cocci, whose virulence 
is lessened? Besides, there are certainly cases of rheumatism 
which are not microbic; those connected with psoriasis seem 
to be neuropathic, those with erythema multiforme non- 
microbic, and the inflammations of joints occasionally caused 
by (Klebs-Lofner) diphtheria antitoxin are surely not so. 

The essential character of rheumatism becomes still more 
dubious when we consider those cases of joint inflammation 
whose connection with known infectious diseases can be proven. 
They are called rheumatoid, and exhibit either pain, or inflam- 
mation, or suppuration. They follow typhoid fever, dysentery, 
parotitis, gonorrhoea, pneumonia, diphtheria, influenza, cere- 
brospinal fever, scarlatina and other acute exanthems, hem- 
orrhagic diathesis, and catarrhal angina, also syphilis. The 
contents of the joint were found to differ in gonorrhoea, pneu- 
monia, diphtheria, and erysipelas; now and then the heart will 
be affected, mainly in scarlatina. In but few of them salicylic 
acid has the same effect which it displays in the majority (only) 
of genuine, independent, acute rheumatisms. In most of them 
antipyrin (with or without salicylates) acts better than sali- 
cylates alone. In syphilitic arthritis, however, it has no effect 
at all; iodides only are useful. 

Altogether, the treatment of acute articular rheumatism has 
been quite unsatisfactory down to a modern time. A few of the 
indications are furnished by the actual or alleged causes of the 



INFECTIOUS DISEASES. 289 

disease. By some it has been believed to be endemic; it is sure 
that certain localities have been known to harbor a great many 
cases at the same time. In these, a change of residence, if 
practicable, ought to be resorted to, provided the individual 
case is but one of a great many in the same neighborhood. 
Contagion has now and then been presumed to cause the 
spreading of the malady; but the number of observations of 
the kind is but very limited indeed. The greatest possible 
care bestowed on those sick with infectious fevers will prove 
a powerful preventive of rheumatic fever. The blood has 
been found to be changed during the latter affection; the 
red cells and haemoglobin are diminished, the white cells 
and fibrin increased. According to many writers, both chemists 
and physicians, the alkaline condition of the blood is less pro- 
nounced. This change, or the actual prevalence of acid in 
the blood, has also been either proved, or assumed to exist, 
in cachectic conditions of many kinds, in fevers, uraemia, 
leucocythaemia, diseases of the liver, in poisoning with acids, 
lead, and mercury, in pyaemia, typhoid fever, gout, and diabetes. 
In them, as in acute rheumatism also, lactic acid has been 
found in an undue proportion. It is the same acid which has 
been found in over-exerted muscles; still, when introduced into 
the circulation, it never produced articular rheumatism. The 
diminution of the alkali of the blood would justify at once the 
administration, through the whole course of an acute rheuma- 
tism, of alkaline salts, and particularly potassium; the latter 
is greatly diminished according to Beneke, who, besides its rela- 
tive absence, looks upon the impairment of nerve-power and 
the accumulation of organic acids as the main factors in the 
pathogenesis of rheumatism. 

Sudden changes of temperature are certainly among the 
causes of acute rheumatism. Cold and moist weather, moist 
houses, exposure to wind and rain will bring it on. This effect 
may be immediate, and consists in the sudden suppression of 
the cutaneous circulation and elimination, or gives rise, by re- 

19 



290 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

flex action, to vasomotor or trophic disturbances in the joints. 
Particularly is that so in those who have inherited a disposition. 
Such an inheritance is not at all infrequent. I have seen acute 
rheumatism in several children of a rheumatic father or mother. 
The treatment of such cases must be mainly preventive. The 
tendency to be influenced by sudden changes of the surround- 
ing temperature can be modified or removed by the systematic 
use of cold water. Children with disposition to rheumatism 
should have a daily cold wash, sponge, or bath. The former 
is the mildest mode of application. They may be rubbed down 
with a wet sheet, and afterwards with a warmed dry and coarse 
bathing towel. Those who have been strengthened by this 
procedure, or such as are stronger, may be sponged, or use a 
shower-bath for a few seconds, or a cold bath. These will be 
well tolerated and prove useful, when the surface, mainly of the 
extremities, becomes warm after a moderate dry friction. Such 
children as feel chilly after these applications, may begin their 
treatment with tepid water and alcohol (4-6 : 1). I ought to 
add here, that this treatment will accomplish its end best when 
throughout the rest of the day great care is used to protect the 
surface. A cold wash or bath, given to harden and strengthen, 
must be combined with warm clothing and bedding to protect. 
Nothing could be more injurious than the exposure of the sur- 
face to wind and rain. The bare knees and calves of the chil- 
dren of vain mothers are foolhardy provocations of the invasion 
of many of the serious diseases. Sea-bathing is a first-class 
roborant, except in the presence of heart-disease. 

The swollen and painful joints must be protected against 
the pressure of blankets or painful handling by raising the bed- 
clothes, keeping the limbs in a basket of proper size (waste- 
paper basket), and covering them thickly with cotton. Well- 
covered splints add greatly to the comfort of the patient. When 
pain and swelling are unusually severe, the application of an 
ice-bag or ice-cloth is advisable. Very young or anaemic chil- 
dren do not bear them long. Cold water will then take the place 



INFECTIOUS DISEASES. 291 

of ice-water or ice. A wet bandage, or pack, round the afflicted 
joint is often borne well and relished. It ought to be changed 
every hour or half hour. Very anaemic and neurotic patients 
prefer hot and dry applications, mainly in those cases in which 
the pain is the principal symptom complained of. To relieve 
the latter I cannot advise the subcutaneous injections of car- 
bolic acid which have been recommended; in very severe cases 
I have been compelled to administer a few drops of a solution 
of morphine hypodermically. As a rule, however, oleate of 
morphine or a mild solution (from two to four per cent.) of 
muriate of cocaine on the skin, a chloroform liniment brushed 
on, chloroform poured into the cotton surrounding the joint 
and retained by oil silk, or a very mild galvanic current now 
and then, also the application of oil of winter-green, will give 
some relief. 

The swelling of the synovial membranes and ligaments in 
retarded convalescence or chronic cases taxes the patience of 
both the sick and the physician. Vesicatories kept on for half 
an hour, and frequently repeated; the wet bandage or pack 
snugly applied so as to compress gently; compression by band- 
ages, or collodion, gentle massage; the galvanic current daily 
applied, find their indications in many and various cases. 
Iodine will come in for its share of usefulness. Besides the 
internal administration of the iodides (potassium or sodium, 
or both combined, in doses of grs. 5-20 daily [0.3-1.25]), the 
external applications will be found beneficial. The officinal 
ointment will act through the gentle handling and kneading 
necessitated by its use. Solutions of the iodide of potassium 
in glycerin will act better, but are inferior to the lanolin oint- 
ment referred to in a former chapter. Superior to all, however, 
is the application, twice daily, of one part of iodoform in from 
eight to fifteen of collodion or flexible collodion. It is brushed 
over the swollen part copiously, and allowed to dry while the 
limb is kept absolutely at rest for ten minutes. Only such 
scales as get detached spontaneously may be removed; other- 



292 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

wise the next application is made on top of the preceding ones. 
Very old cases, with chronic effusion into the joint, require 
aspiration and washing out. These manipulations have become 
safe in the hands of every physician who learned the use of soap 
and of disinfectants on himself and his instruments since oper- 
ative surgery availed itself of the immense progress made in 
pharmacological laboratories. 

Endocarditis demands absolute rest, both of the organ and 
the body. Every exertion will prove injurious. Thus an occa- 
sional dose of opium or of a bromide, or of both combined, and 
the use of iodide of potassium in daily doses of from one-half 
to one gramme, have a good effect. The application of an ice- 
bag to the cardiac region, or, when that proves too heavy, an 
iced cloth, acts very favorably indeed. But not every murmur 
means endocarditis; it may be the result of muscular incom- 
petency or irregular contraction only, and quite temporary; it 
is sometimes observed in cases of but moderate severity, and 
mainly combined, or alternating with, or preceding chorea 
minor, which now and then makes its appearance in the very 
earliest period of acute rheumatism. Both chorea and endo- 
carditis can be mitigated or prevented by early attention. If 
every case of incipient rheumatism were sent to bed, if no 
"growing pain" were allowed to be on the play-ground, or at 
school, many a life-long ailment and early death would be 
avoided. 

The temperature is but rarely high, or rather there are a 
great many cases of articular rheumatism in infants and chil- 
dren in which the temperature is as little elevated as the rest 
of the symptoms urgent. But there are such as have rectal 
temperatures of from 104° to 107° and more. It is in these 
that delirium and other cerebral symptoms, and paralytic res- 
piration and collapse, may make their appearance, and that the 
most efficient antipyretics must be employed. Among them the 
cold pack, as described in a former chapter, and applied to the 
trunk and lower extremities as far down as the knees, is the 



INFECTIOUS DISEASES. 293 

readiest and most effective remedy. It is particularly indicated 
in cases complicated with endocarditis; it is in these that anti- 
pyrin, acetanilide ("antifebrin"), and phenacetin will not 
always have a pleasant effect. All of them are inferior to the 
salicylate of sodium in regard to antirheumatic and antipyretic 
action. A child of three years may take from six to ten grains 
(0.4-0.6) every two or three hours, for one or more days. This 
is the less dangerous the more the symptoms of overdoses are 
understood. When they appear (mainly the brain symptoms, 
tinnitus, stupor, paralytic or interrupted, sighing, respiration) 
ample time is given for the discontinuation of the drug; a single 
large dose for the night, of from ten to twenty-five grains 
(0.6-1.5), succeeds better, sometimes, than the many smaller 
ones. As a rule, salicylate of sodium mitigates the symptoms 
of pain, swelling, and fever very soon. Many of the patients 
feel very much better after the lapse of a day; then the doses 
may be diminished or administered at longer intervals. Longer 
than from three to five days it ought not to be given; if no 
effect, or an insufficient one only, be obtained after that time, 
no further reliance need be bestowed on it. Then antipyrin, 
antifebrin, or phenacetin may accomplish what the salicylate 
failed in. In the same way salol, salicin, and cresotic and 
benzoic acids have been recommended. Lactophenin has been 
unsatisfactory. Salipyrin in three or four daily doses of from 
four to ten grains (0.25-0.6) acted more favorably. 

At the same time, particularly when there is a constant ten- 
dency on the part of the temperature to rise either permanently 
or periodically, sulphate (or another preparation) of quinine 
may be administered in one or two doses of from five to eight 
grains (0.3-0.5) each. The most opportune time is the period 
of remission which mostly takes place in the morning. Alka- 
line salts may be given alongside the other medication, alkaline 
mineral waters, such as Seltzer or Vichy or bicarbonate of 
sodium, from a scruple to a drachm (1.0-4.0) daily, or citrate of 
potassium, or the bitartrate; or one of the nitrates which have 



294 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

formerly been credited with almost a specific action. Vegetable 
acids have been warmly recommended, such as citric acid. 
They take the place of alkaline salts, inasmuch as they are elim- 
inated as carbonates. The iodides of potassium and sodium 
have been esteemed very highly, — justly so, indeed, — particu- 
larly as the tendency to chronicity renders desirable the per- 
sistent effect of a powerful absorbent. Of the other remedies, 
which have been given for their alleged specific effect (colchi- 
cum, colchicin, veratrum, aconite), I have seen but little effect 
in acute rheumatism of infancy and childhood. They, too, 
render better service in the cases which have become or are 
fast becoming chronic. 

During the attack of an acute, or subacute, articular rheu- 
matism the diet should be strictly milk, farinaceous food, light 
vegetables, and fruit. Meat and alcoholic beverages are posi- 
tively forbidden. 

Gonorrheal articular rheumatism is not excessively rare 
among infants and children, though direct sexual intercourse 
be not frequent at that age. It is not at all confined to one or 
a few joints, or to those of the lower extremities; it is subacute 
mostly; the effusion is liable to be excessive, and apt to be 
purulent. The latter condition, being dangerous partly to the 
joint, and partly through its tendency to infect the body, must 
be watched carefully; for it is often the beginning, or part, of 
a general pyaemia; in a few instances I have seen the eye de- 
stroyed by panophthalmitis in twenty-four hours, and the child 
died, after weeks of suffering, of the general infection. There 
are also cases of septic endocarditis. The cause is often what 
is easily taken for a common vaginal catarrh, but is gonorrhoea. 
The long time the latter may be concealed, unchanged in its 
contagiousness, within the vagina of the adult, and the facility 
of communicating it to the young by direct contact or mediate 
communication through towels, bedclothes, etc., yield a clue 
to certain otherwise unexplainable cases. In a small child's 
institution I saw a dozen cases at one time. The treatment of 



INFECTIOUS DISEASES. 295 

the diseased vagina has its own indications. That of the joint 
affected with gonorrheal rheumatism must be more local than 
the average case. An aseptic puncture may be made for the 
purpose of ascertaining the contents of the synovial cavity. If 
there be pus, it must be removed and the cavity washed out, 
thoroughly disinfected, the limb rested on a splint and gently 
compressed; if serum in large quantity, puncture may become 
necessary when other treatment becomes unavailing. Other- 
wise gentle but steady compression by bandages, with or with- 
out mercurial plaster underneath, or by iodoform collodion, are 
indicated; at the same time the use of salicylate of sodium and 
iodide of potassium and (or) sodium must be continued a long 
time. 

During and after an attack of acute articular rheumatism 
there will be noticed, occasionally, small neoplasms on tendons 
and the insertions of muscles, on fasciae, and on periosteum, 
varying in size, numbers, and sensitiveness, which consist of 
young connective tissue with numerous cells, last from a few 
days to several months, and give rise to but little elevation of 
temperature. Sometimes they are the very last, or only remain- 
ing, symptoms of the disease; now and then a new endocarditis 
has been observed to make its appearance with them. This 
"nodulated rheumatism" "rheumatismus nodosus," is more fre- 
quent in children than in adults; the oldest patient in whom I 
have seen it was a boy of eighteen years. In his case the inser- 
tion of the occipital muscle was the principal seat of the nod- 
ules, dozens of which, from the size of a pea to that of a small 
hazel-nut, could early be distinguished. From syphilitic gum- 
mata, fibromata, gout, and cutaneous tubercles they can be dis- 
tinguished easily. Special therapeutics for this form there is 
none. But endocarditis is a frequent occurrence. 

Peliosis rlieumatica is the name of a peculiar form of more 
or less localized purpura. In some cases of rheumatism a large 
number of small subcutaneous and cutaneous hemorrhages 
appear mostly on the lower extremities, and mainly round the 



296 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

joints. Now and then they are painful, but frequently not 
sensitive at all. In this they do not differ from common pur- 
pura. In a number of cases of peliosis the heart was not found 
affected; and the inference has often been drawn that peliosis 
is no rheumatism at all. Indeed, purpuric hemorrhages are 
often noticed in other infectious diseases (typhoid, measles, 
whooping-cough, pneumonia, Bright's disease, syphilis, mer- 
curialism), and not infrequently round the malleoli and the 
joints in general (maybe in consequence of the impediment to 
circulation resulting from the smaller amount of subcutaneous 
fat and consequent tension of the integument in those regions), 
and in a number of instances the accompanying articular pains 
of such constitutional diseases are best explained by the pres- 
ence of hemorrhages inside. Still, peliosis will sometimes ap- 
pear quite early in acute rheumatism; these are the cases which 
were classified as a specific variety, and that is why peliosis was 
claimed to be a specific rheumatic affection. If so, it requires no 
special treatment; but the structural condition of the walls of 
the blood-vessels (and insufficient innervation and the presence 
of specific bacilli ?), which causes the hemorrhages, indicates 
the early administration of roborants and cardiac stimulants 
through the whole course of the disease, and great caution in 
the doses and quantities of salicylate of sodium, which has 
rather a disposition to increase the hemorrhagic tendency. 

There are a great many varieties, or rather degrees, of pelio- 
sis, similarly to what we know to take place in purpura. Ac- 
cording to whether the hemorrhage takes place near the surface 
or in the deeper layers of the tissue, both the color and the mas- 
siveness of the hemorrhage will differ. In some cases the result 
is an erythema, which has been called either papillosum or nodo- 
sum from the differences in the results of inspection and pal- 
pation. It is observed both in severe and mild cases of articu- 
lar rheumatism; it is somewhat raised above the level of the 
skin, sometimes deeply inserted and then circumscribed; and 
frequently found near the joints. In accordance with the indi- 



INFECTIOUS DISEASES. 297 

cations furnished by rheumatismus nodosus and peliosis no 
special therapeutics is required for this form. 

Chronic articular rheumatism is but rare in childhood. Mon- 
corvo reports the case of a girl of two and a half years, whose 
rheumatism began with an acute attack, became chronic, and 
was finally cured by the galvanic current administered for a 
long time in succession. The youngest case of mine, also a 
girl, was five years old. She was puny and feeble, and her gen- 
eral nutrition defective. A number of the large and small 
joints, particularly of the hands, was affected, and the tumefac- 
tions of the ends of the bones were quite marked. There was 
neither an affection of the voluntary muscles nor of the heart, 
and no disease of any part of the nervous system, which 
Mitchell (1831) and Charcot (1868) found to be the cause of 
"arthropathia swellings. The treatment is about the same 
which is resorted to in the same disease when met in the adult. 
Salicylate of sodium should be given in those cases only which 
exhibit acute exacerbations. Colchicum, aconite, iodides will 
take its place, and will be required for a long period. Small 
doses of arsenous acid, from one-three-hundredth to one-five- 
hundredth of a grain (one-eighth to one-fifth of a milli- 
gramme) every two or three hours, will answer well. Prolonged 
warm baths, salt-water baths (cold or warm), and sulphur baths 
will improve many a case; so will galvanism and massage. 
Others will be benefited by dry heat of a high temperature, 
which increases tissue metamorphosis to a remarkable extent, 
mainly the amount of uric acid. As external treatment a di- 
luted tincture of iodine, iodoform ointment, iodoform collo- 
dion, or the iodide of potassium and lanolin ointment can ren- 
der good service. Narcotics are seldom required. Good results 
are obtained by the protracted use of alkaline waters. From 
what little I have seen of chronic rheumatism in children, and 
the many cases of the same disease in the adult, I recommend 
strongly the use of large quantities of water, to which is added 
from a scruple to half a drachm (1.0-2.0) of the bicarbonate 



298 THERAPEUTICS. OF INFANCY AND CHILDHOOD. 

of potassium as a daily dose; also lithium carbonate in daily- 
doses of from four to ten grains (0.25-0.6). Our natural lithia 
waters contain too little lithia to have any effect except through 
the large amounts of water consumed. 

Muscular rheumatism can be diagnosticated occasionally in 
very young children; in those from six to twelve years it is not 
so very rare. Its nature and symptoms do not differ from 
those in the adult. The neck, back, and shoulders are most 
frequently affected. The best preventive is the habitual use of 
cold water. Diaphoretics are not very useful. Narcotic and 
stimulating liniments find their own indications. Oleate of 
morphine is of but little use; in a severe case I have injected 
a small dose of morphine with immediate and permanent effect. 
The interrupted current acts promptly in one or more sessions. 
Salicylate of sodium, antipyrin, antifibrin, and phenacetin 
have a speedy effect, in proper doses and frequently repeated. 
Semmola's experience in a severe case of neuro-muscular rheu- 
matism is worth remembering. The case was that of a woman 
of forty years, who suffered from stiffness and pain in a shoul- 
der and right arm, with good passive motility of the joint. 
After the pain had lasted several months, massage, electricity, 
quinine, and salicylic acid having proved inefficient, the patient 
was relieved in a few days by a few subcutaneous doses of one- 
twelfth of a grain of pilocarpine. 

It is in rare cases only that the rheumatic process in the mus- 
cle assumes the character of an inflammatory affection. Then 
there is, as in every myositis with a tendency to chronicity, a 
hyperplasia of the connective tissue between the fibrillar, the 
muscle becomes hard and somewhat shorter, its electrical irri- 
tability grows less or disappears, the skin even participates in 
the process. Such a case I once observed in a boy of twelve 
years. He never was entirely relieved, but greatly improved 
by massage, warm bathing, a mild continuous current, and the 
internal administration of hydrargyrum bichloride. The treat- 
ment was continued through more than a year. 



INFECTIOUS DISEASES. 299 

21. Influenza. 
Epidemic bronchitis, influenza, can be prevented only by 
avoiding contagion, which is even more difficult than it is 
to escape measles. Its treatment depends a great deal on the 
variety; the catarrhal, gastric, and intestinal symptoms require 
early attention, for nervous exhaustion is imminent in every 
case, and many patients suffer more seriously from the sequelae 
than from the original attack. Antipyretics cannot always be 
avoided. Phenacetin, antipyrin, and salicylate of sodium, com- 
bined with a cardiac stimulant, may be thus employed, partic- 
ularly when muscular pain is one of the prominent complaints. 
Quinine also finds its ready indication. Opiates are often re- 
quired, either in small and frequent doses or in a single larger 
dose to secure sleep. Inhalations of steam, two per cent, of 
carbolic acid having been added to the water, have been highly 
recommended, but whatever adds to the bronchial irritation 
and produces cough should be avoided. Rest in bed is required 
long after apparent recovery, for collapse and nervous symp- 
toms of many kinds are liable to appear during convalescence, 
and there is no case, though apparently ever so mild, that may 
not turn out grave. Besides vomiting, diarrhoea, high tempera- 
ture, great lassitude, and all the symptoms of catarrh and in- 
flammation of the mucous membranes, complications with seri- 
ous forms of pneumonia and pleurisy, of diseases of the heart 
and the sensory organs, and of the nervous system (mental dis- 
orders included) are frequent. Among the ocular symptoms 
conjunctivitis is frequent, keratitis and iritis are met with, irido- 
choreitis and retinitis are not so frequent as acute glaucoma. 
Now and then atrophy of the optic nerve has been observed. 
Otitis media with mastoid abscess is not uncommon; hemor- 
rhagic myringitis requires incision. Meningitis and pyaemia 
are among the sequelae. Most frequent is utter exhaustion, 
which appears to be more than merely functional, and requires 
for weeks and months (years) the most careful and persistent 
roborant and stimulant measures. 



300 THERAPEUTICS OF INFANCY AND CHILDHOOD. 



22. Pertussis. 

The mortality from whooping-cough in New York City is as 
great as that from typhoid fever. Twenty-five per cent, of all 
the cases under a year terminate fatally; five per cent, of all 
those between the first and fifth year, and one per cent, of all 
those occurring after the fifth. Its direct mortality, however, is 
not the only danger, for not infrequently chronic laryngitis, 
pneumonia, emphysema, dilatation of bronchi, and the result of 
hemorrhages which occur during the attacks (convulsions, 
paralysis, either general or local, blindness), impair the health 
of the patient for many years or a lifetime. Thus the tendency 
of allowing whooping-cough to run its full course oh the plea 
that it is a self-limited disease, or that every child must have 
his whooping-cough, is certainly not justified. 

The prevention of whooping-cough, which is a specific and 
contagious disease, is certainly not easy, for the reason that 
contagion may take place very suddenly, and through the first 
and second stages of the disease, both of which extend over a 
large number of weeks. Contagion may take place, no matter 
whether the cause is to be looked for in the presence of micro- 
organisms or not, by means of the exhaled air, or mucus, or the 
masses brought up by vomiting. Prevention means protection 
against the effects of all these factors. 

As the disease is spread by contagion only, isolation is an 
absolute necessity, difficult though it be. In public institu- 
tions it is impossible. Thus no patient ought to be admitted 
to, or allowed to remain in, a public school or a hotel inhabited 
by children. Whooping-cough children must not even be per- 
mitted to congregate in large numbers, because the cases will 
become more severe by their mutually affecting each other. In 
one point only isolation is more effective in whooping-cough 
than in other contagious diseases, — namely, in this, that the 
disease does not appear to be carried by persons not thus af- 
fected. 



INFECTIOUS DISEASES. 301 

The air must be kept pure, uniform, and moderately warm. 
No wind or draught, however, must be permitted. Utensils 
must be kept clean and be disinfected, and the masses brought 
up by vomiting disinfected, destroyed, or removed. The mucous 
membranes should be kept in, or restored to, a healthy condi- 
tion, particularly those of the mouth and respiratory organs. 
Thus no injudicious exposure must be allowed. The digestive 
organs have to be watched, the stomach must not be full at any 
time, the bowels kept regular, the food be digestible. 

As long as the microbic cause of the disease is not known, 
and therefore no causal indication can be fulfilled, the object of 
treatment limits itself to this: to relieve the severity and di- 
minish the number of the attacks, to procure quiet nights, to 
stop the vomiting, to shorten the course of the disease, and to 
prevent detrimental consequences. 

An important indication is that of treating a catarrhal or 
inflamed mucous membrane. It is quite possible that a sore 
mucous membrane only is capable of admitting the contagion 
of whooping-cough as it mostly does that of other infectious 
diseases, for instance diphtheria. Besides, by attending to the 
mucous membranes in time, the occurrence of serious complica- 
tions, such as pneumonia, may be prevented. Catarrh of the 
mouth and pharynx ought to be treated with doses of chlorate 
of potassium of from half a grain to a grain (0.03-0.06) in a 
teaspoonful of water every hour; and a large number of our ex- 
pectorants find their ready indications in such cases. All of 
those which have a depressing effect should be avoided,, particu- 
larly antimonials. Even ipecac should be given in small doses 
only. Alkaline waters have a beneficial effect. The muriate of 
ammonia in doses of from half a grain to two grains (0.03- 
0.125) every hour or two hours will liquefy the viscid secretion 
of the bronchial mucous membrane. In a state of evaporation, 
as described in a former essay, it may be inhaled. The inhala- 
tion of other agents, which have been recommended as expec- 
torants, will at the same time act by its germicidal action, so the 



302 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

vapors of benzol, of carbolic acid, and cresolin; and the reputa- 
tion obtained by gas-works in the treatment of whooping-cough 
is thus finding its ready explanation. 

The effect attributed to astringents in the treatment of 
whooping-cough is best explained by their action on the mu- 
cous membranes. Particularly alum and tannin have been so 
employed. Emetics have been recommended for the purpose 
of relieving the surfaces of sticky mucus difficult to remove. 
Sulphate of copper or zinc, ipecac powdered, or turpeth min- 
eral are the proper substances to be selected for that purpose. 

Schliep has seen good effects of the use of the pneumatic 
chamber in whooping-cough. He kept the children with their 
mothers or attendants in compressed air. In a few cases a few 
sessions of two hours each were sufficient to relieve the patients 
considerably. In a number of cases from twelve to twenty ses- 
sions were required. In all of them he claims decided effects, 
not only in the reduction of the number and severity of the 
attacks, but also in the duration of the disease. The explana- 
tion of the good effect is looked for as well in the increased 
amount of oxygen inhaled as in the diminution of the hyper- 
aemia of the mucous membrane. I believe the plan is a good 
one, particularly if it could be combined with the inhalation of 
turpentine. 

Caille (Arch. Ped., August, 1892) says that ozone inhalations 
have a very distinct curative effect as regards the duration and 
severity of the disease. 

Cases exhibiting a severe degree of pharyngitis and laryngeal 
hyperemia, particularly in children who have suffered a long 
time from chronic inflammatory affections of those parts, will 
do well, as far as the local symptoms are concerned, under the 
use of the tincture of pimpinella saxifraga; a drachm (4.0) dis- 
tributed over the twenty-four hours will be the proper dose for 
a child of from two to three years. 

Local treatment has been resorted to by many. The pharynx 
has been treated locally with a solution of quinine (Hagen- 



i^m 



INFECTIOUS DISEASES. 303 

bach), a two-per-cent. solution of resorcin (Moncorvo), a one- 
per-mille solution of bichloride of mercury, a one- or two-per- 
cent, solution of nitrate of silver, a five-per-cent. solution of 
hydrochlorate of cocaine, a four- or six-per-cent. solution of 
bromide of potassium. Applications have also been made di- 
rectly to the larynx of quinine mixed with bicarbonate of so- 
dium in different proportions, of mild solutions of salicylic acid, 
and of powdered sulphur. Inhalations have been resorted to, 
besides those enumerated above, of sulphurous acid, and ex- 
tolled as highly as any of those which have been mentioned. 
If they prove anything, they and the great number of the reme- 
dies recommended for the same purpose speak for the difficulty 
encountered in the treatment of whooping-cough, and for the 
confidence of the practitioner in the patience and submission of 
his wards. Michael treats whooping-cough as a neurosis, with 
the same means he employs against other neuroses attributable 
or attributed to nasal irritation. He claims that seventy-five 
per cent, of his cases of whooping-cough have done well when 
exposed to the influence of quinine, bromide of potassium, ben- 
zol, tannin, boracic acid, salicylic acid, iodoform, cocaine, bicar- 
bonate of sodium, or prepared chalk applied to the mucous 
membrane of the nares. 

The internal administration of chloral hydrate, or croton 
chloral hydrate, has been recommended by Lorey in 1879. The 
daily doses range from eight to fifteen grains (0.5-1.0). In all 
cases the attacks became less severe within a short time, but 
the disease itself was not shortened. Kennedy expresses him- 
self very enthusiastically in regard to the effect of the remedy, 
which is given by itself or combined with the bromide of potas- 
sium. To procure an occasional good night, a single dose of 
from six to twelve (0.4-0.75) grains has rendered me good ser- 
vice. 

Rest and sleep should be enforced. W. W. Johnston's (Arch. 
Ped. y April, 1895) advice to keep whooping-cough children in 
bed is good. In that way isolation, rest, and equable tempera- 



304 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

ture are secured, and the results of the feebleness and dilatation 
of the heart are avoided. 

The inhalation of chloroform, or, according to some, of ether, 
can be recommended in those cases in which convulsions have 
either occurred during severe attacks, or in which the interrup- 
tion of the circulation is such that cerebral hemorrhage or con- 
vulsions must be feared. In the case of a very young infant 
I have administered chloroform once every hour for every new 
attack during the course of a number of days in succession for 
that very purpose, with beneficial result. 

Quinine has been used both internally and externally by a 
number of authors of good repute. It was first recommended 
by Letzerich, who claimed to have found the cause of whoop- 
ing-cough in a coccus. That coccus has not been found to this 
very day to be the omnipresent cause of the disease, but still 
quinine has found favor for a number of reasons. Eossbach 
credits the drug with the power of relieving increased reflex 
irritability; Binz, however, attributes to it an antizymotic ac- 
tion. He gives as many decigrammes daily as the child has 
years, so that a child of five years takes eight grains of quinine 
a day. He expects to find an improvement after two or three 
days, inasmuch as the attacks are said to become by that time 
shorter and less severe. Where it cannot be given internally, 
he administers it in suppositories or in injections. "Where the 
sulphate or hydrochlorate are not tolerated, the neutral tannate 
of quinine is selected instead, with this proviso, however, that 
the latter salt is much weaker than the former, and has to be 
administered in doses from two to three times as large. It has 
the advantage of being tasteless. In our own country it is par- 
ticularly Forchheimer who advocates quinine. He reported 
ninety-seven cases as having been benefited by its administra- 
tion. 

Antipyrin has been recommended for whooping-cough, since 
1886, by Demuth, Sonnenberger, Moncorvo, Guaita, Wendt, 
and many others, as almost a specific. Like all the other chemi- 



INFECTIOUS DISEASES. 305 

cal relatives of chinolin, it destroys parasites outside the or- 
ganism. It has been claimed, or presumed, that it displays the 
same effect inside. Whether that is true remains to be seen. At 
all events, however, it is a powerful nervine. It is claimed that 
it can be given with the same beneficial result in the beginning 
of the disease and in its most severe stage, and that the latter 
will terminate favorably in from four to five weeks after the 
beginning of the treatment. The dose is from a grain and a 
half to two grains (0.1-0.125) three or four times a day for 
every year of the patient, with an occasional large dose for the 
night. 

Tussol, the amygdalate of antipyrin, is given in the same 
doses as antipyrin. As H. Eehn recommends it quite highly, it 
should be tried. It must not be given in milk, nor in close 
proximity to it. 

Of all the almost countless medicines advised against whoop- 
ing-cough I prize belladonna most highly. I have always re- 
turned to it after having discontinued it for the purpose of try- 
ing one after the other of the many remedies recommended 
during these thirty years. As early as 1861 I had occasion to 
express, in the American Medical Monthly, the following 
opinion: 

"Belladonna is the most powerful remedy in whooping- 
cough. I scarcely remember a single case in which its adminis- 
tration, for years past, proved unsuccessful in shortening the 
duration of the process. The result obtained by me has gen- 
erally been this: that a well-developed case of whooping-cough, 
after the diagnosis was made certain beyond a doubt, would 
last for only three or five weeks longer, instead of running 
through its full course of months and quarters of a year. The 
effect is mostly not a sudden one. Many cases in which bel- 
ladonna is given from the first commencement will become 
worse for a short while, then remain at their height for some 
days or a week, and gradually improve in both the character 
and frequency of the attacks. In others the effect is percepti- 

20 



306 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

ble from the first days after their administration; the cases 
soon assuming a more favorable aspect. Such has been my 
uniform experience during the last five years, in each of which 
the children of this city have been suffering from a more or 
less severe epidemic. 

"My readers, many of whom have doubtless been in the habit 
of prescribing belladonna in whooping-cough with more or less 
marked success, need hardly be assured that I claim no priority. 
Belladonna has been recommended in this disease for many 
decades, and has just as long been objected to, as either useless 
or dangerous. I have touched upon the subject because of my 
conviction that both the former objection and the latter fear 
are groundless. 

"Belladonna is well known to produce readily symptoms of 
poisoning. An amount of two and a half or three grains taken 
by an adult in the course of a day, of either root or extract, has 
the effect of dilating the pupils, causing a feeling of dryness in 
the throat, scintillation and giddiness, and even erythema of 
the skin. This latter effect is, however, not frequently seen in 
adults, while the effects on the pupil and brain are very com- 
mon. It was therefore believed that, as nervous disorders are 
as common as they are dangerous in infantile age, these effects 
ought to counterindicate its use; it was stated that it would 
cause congestion, sopor, acute hydrocephalus, and idiocy; and 
the practical consequence simply was that the dose of the 
remedy, when given at all in a case where it appeared to be in- 
dicated, was entirely too small. Thus, doses of a sixtieth, a 
forty-eighth, a thirtieth of a grain of extract of belladonna, re- 
peated three or four times a day, were deemed sufficient and 
proper. These doses could not but prove unsatisfactory, and 
thus it happened that the remedy was misappreciated and given 
up. The doses, however, administered by me proved successful, 
because they were sufficient. 

"Infants of six or eight months of age affected with whoop- 
ing-cough require a sixth of a grain (0.01) of either the root or 



INFECTIOUS DISEASES. 307 

the alcoholic extract three times a day; children of three or 
four years tolerate three doses, each of half a grain (0.03). 
These doses appear to be very large in proportion to those toler- 
ated by adults, but it is a fact which can easily be verified, that 
the effect of belladonna on the pupil and brain will hardly 
ever be perceptible in children from these or smaller doses. 
The succession of belladonna symptoms in children differs, 
moreover, altogether from that in adults; the erythematous and 
flushed appearance of the face and neck, sometimes even of the 
whole surface, is the first symptom in infantile age; whereas 
it is seldom observed in adults, or in cases of thorough poison- 
ing only. Some of the old authors advised the administration of 
belladonna to such an extent as to produce the first symptoms 
of poisoning; others, however, objected to this practice as dan- 
gerous. I, for my part, soon found that those children suffer- 
ing from whooping-cough who exhibited general erythema 
from an apparent overdose recovered soon, while others, in 
whom no such symptom was observed, remained sick for a long 
time; and continued experience has proved that the occurrence 
of this symptom is absolutely necessary for the full remedial 
effect. To obtain control of whooping-cough, the remedy 
must be given in a dose sufficient to produce erythema, or at 
least a flushed condition of the face, and, as it were, feverish 
appearance after every dose of belladonna. Thus the dose is 
to be gradually increased until this result is obtained. It is a 
remarkable fact that very young infants may take proportion- 
ately large doses: at all events, I do not remember a single 
case in which less than half a grain was taken in the course of 
a day. The prescriptions I have been in the habit of ordering 
are very simple ones. I either give the medicament as a pow- 
der, or have the extract dissolved and sweetened according to 
circumstances. 

"The administration of belladonna alone is indicated in such 
cases of whooping-cough as are not complicated with inflamma- 
tory affections of the respiratory organs. The latter take the 



308 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

lead in complicated cases as well in treatment as in the nature 
and gravity of the symptoms. This is so certain that, whenever 
a pneumonia coincides with or follows whooping-cough, the 
peculiar sound of the cough of the latter will disappear, and 
return only when the inflammation begins to give way. As 
this is, moreover, the most dangerous of the two, it requires at- 
tention before the other. As to bronchial and laryngeal ca- 
tarrh, the former especially is a very common symptom in 
whooping-cough. Where it is but slight it may be considered 
as unimportant; where, however, it gives rise to fever or dysp- 
noea, it constitutes a further indication to interfere." 

The preparations mentioned above need not be the only ones 
to be relied on. The tincture of belladonna is a convenient 
remedy, inasmuch as the dose can be readily and gradually in- 
creased. A baby of two years may take three daily doses, the 
first of which may be six drops. If the flush be perceptible 
within twenty or thirty minutes, that is the dose; if not, the 
number of drops must be increased to obtain the effect which is 
demanded after every dose. After a few days larger doses are 
required; there is no case but demands at least twice the 
amount of the original dose of belladonna within ten or twelve 
days, or before the disease disappears. Atropiae sulphas may 
take the place of belladonna. A child of two years will proba- 
bly begin with the five-hundredth part of a grain, to be given 
three times daily, and increased according to the rules stated 
before. 

Since that early time alluded to, Vogel speaks highly of 
the effect of belladonna, taking the dilatation of the pupils as 
a guide. As I have mentioned, this effect is rather late in 
appearing in children, and is not required; indeed, it may 
become quite uncomfortable. Meigs and Pepper combine 
belladonna and alum. Evans, in the Glasgow Medical Journal 
of 1880, recommends the administration of a large dose first, 
to be followed by smaller ones afterwards, and there are not a 
few authors who have seen immediate good effect following the 



INFECTIOUS DISEASES. 309 

intended or accidental administration of a large, almost poi- 
sonous, dose. Indeed, the number of practitioners now relying 
on the effect of belladonna in whooping-cough is quite large, 
no matter whether they look for the beneficial action on the 
laryngeal and other branches of the pneumogastric nerve or on 
the medulla oblongata, or rely on its influence in modifying 
reflex action. 

Opium is spoken of favorably by a great many. I cannot 
recommend it for anything like regular administration, but it 
certainly has a good effect in procuring fair nights when given 
in a single dose. A grain of Dover's powder given to a child 
of two years, at bedtime, will at all events have the effect of 
procuring sleep. In a number of cases the combination of 
opium and belladonna acts quite well. The antagonistic effect 
claimed for these two drugs is not such as to interfere with the 
combination of their effects as sedatives. 

Netter (La Semaine Med., 1886, p. 321) recommends the 
oxymel scillae (No. 287 of the "National Formulary of Un- 
ofncinal Preparations," revised edition) for whooping-cough, 
and prescribes it in the following manner: After having taken 
food between three and four o'clock, the child is given a tea- 
spoonful every ten minutes; those under three years take four 
or five, those over three years six or seven, and adults seven or 
eight teaspoonfuls in the course of an hour. Food is again per- 
mitted at seven o'clock. In this way the administration of the 
drug is continued. It is claimed that both the number and the 
frequency of the attacks become less, but nothing is said of 
the duration of the disease. 

I. Widowitz (Wien. med. Woch., 1888, No. 17) has employed 
the same remedy in one hundred and forty-nine cases. Both 
the number and the severity of the attacks are stated to 
have become less after a single administration in fifty-nine; 
in twenty-four that result was accomplished after the second, 
and in nineteen after the third or fourth administration. In 
twelve per cent, there was no favorable result at all. The 



310 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

duration of the disease was not changed. M. T. Schnirer (Arch, 
f. Kinderh., 1889, p. 447) arrives at the same conclusions, and 
suggests therefore the combination of oxymel scillse with some 
antimycotic treatment. I should rather propose its combina- 
tion with belladonna. Bromoform in three or four daily doses 
of from two to six minims has been highly recommended by 
Stepp, and in New York by Dr. Louis Fischer. A case of poi- 
soning by doses of two drops in a mixture of alcohol, water, and 
sugar, every four hours, with the symptoms of excitement and 
coma, got well under the use of strychnia. 



VI. 

DISEASES OF THE NERVOUS SYSTEM. 

1. General Indications. 

The great indication in the treatment of all diseases of the 
nervous system attended by symptoms of irritation is absolute 
protection against external disturbances. This is attained by 
equable climate, uniform temperature of the room, rest in bed, 
exclusion of light and noise, by comfortably warm clothing, 
warm bathing, warm applications and fomentations, and by the 
removal of anything and everything annoying and jarring. 
Therefore, children sick with nervous diseases must not be ex- 
cited by unnecessary constraint or coercion, their medicines 
ought to be given in a palatable form, and vesicatories and 
other distressing applications avoided, if possible. Sympto- 
matic treatment is perhaps more indicated than in the same 
class of ailments among adults. Pain and sleeplessness lead to 
speedy exhaustion. Nothing is more common and more dan- 
gerous than the prejudiced refusal to relieve pain by opiates 
and sleeplessness by properly selected hypnotics. It is particu- 
larly in those cases which are mostly, or entirely, of a reflex 
nature that a symptomatic treatment ought to accompany that 
of the causal indications. It is ludicrous as well as criminal to 
withhold chloroform when an eclamptic attack results from an 
intestinal irritation, or an antispasmodic when a cough is 
caused by stomach, ear, or nose. 

In conditions of depression, debility, and paralysis the treat- 
ment should be stimulant, exciting, and roborant. In such 
cases the electric current is frequently employed, and is, to a 
certain extent, useful. Massage has a beneficial effect not only 

311 



312 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

on the periphery, but by its general action on innervation 
and circulation, by its effect on the muscles, and also by 
its direct influence in increasing the relative circulation of the 
red blood-cells (John K. Mitchell).* Strychnine stimulates 
(while curare depresses) the reflex and vasomotor centres. Ni- 
trate of silver appears to exert a favorable influence in spinal 
paralyses; muscarine, physostigmine, and nicotine in paralytic 
conditions of the unstriped muscular fibres. 

The interrupted electrical (faradic) current is an excitant — 
stimulant — of the nervous system, both locally and generally. 
For the latter effect general faradization has been practised, 
both through large electrodes and in the bath, to great advan- 
tage, according to many who have a right to claim a large 
experience. The generally stimulant effect does not, however, 
disprove the fact that, like the galvanic, the faradic bath is 
capable, particularly when the fine wire coil is used, of reducing 
undue sensitiveness. The action of the galvanic current is 
claimed to show itself in different ways. It is stimulant and 
excitant, and (directly, or when interrupted by reversing), 
mainly when the brush is employed, produces pain, contraction, 
and consecutive dilatation of blood-vessels. It is electro-tonic, 

* General massage (with dry hands) of the whole nude body, of 
extremities, neck, and trunk, lasting from fifteen to thirty minutes, is 
indicated in anaemia, chlorosis, tedious convalescence, chronic rheuma- 
tism, and neurasthenia. To reach the muscles some force should be 
used, but no violence, which is liable to cause capillary hemorrhages. 
Acute pain, local inflammations, and the presence of pus are contra- 
indications. The circulation of blood and lymph is best stimulated by 
massage of the whole length of the muscles. The lymph-ducts run 
along the intrafibrillar connective tissue. By compressing and empty- 
ing them and the blood-vessels from the peripherous ends in the direc- 
tion of the centre of circulation a new supply is furnished and the 
general nutrition improved. Locally it acts well in recent injuries, con- 
tusions, and distorsions, in subacute and chronic inflammations of 
joints, in neuroses, contractures, arthritis deformans, and arthritic mus- 
cular atrophy (Hoffa). 



DISEASES OF THE NERVOUS SYSTEM. 313 

and thereby produces changes in the irritability of the tissues; 
it is chemical, and thereby decomposes fluids; and it is cata- 
phoric, and thereby transfers solutions through badly conduct- 
ing tissues. To the two poles different properties are attributed. 
It is the positive pole (anode) which is credited with a tranquil- 
lizing effect in inflammations and neuralgias (less in tic and 
hemicrania than in supraorbital, occipital, intercostal, lumbar, 
and sciatic neuralgias); the negative (cathode) is claimed to 
influence old inflammatory processes, cicatrices, and indura- 
tions. Still, there is no doubt in my mind as to the exaggerated 
character of the expectations once cherished in regard to the 
effects to be obtained by both electricity and galvanism. The 
difficulty of reaching a coveted spot through tissues of different 
conducting powers is always great; the accumulation of fat is 
a powerful obstacle to the transmission of the current, and its 
amount cannot be calculated. This is so true that even for pur- 
poses of diagnosis the subcutaneous fat of babies and of many 
women offers a serious impediment. Besides, different morbid 
conditions and different periods of life interfere with the esti- 
mation of the effect of the current. In what has been called 
the reaction of degeneration both the faradic and the galvanic 
irritability of the nerves are diminished and while the galvanic 
excitability of the muscles is preserved, the excitability by the 
faradic current is lowered. In the very young, — the baby 
under two months, — as general reflex irritability is quite low, 
comparatively strong electrical influences are required to obtain 
effects. At all events, therefore, the action of the different 
currents is, to some extent, not measurable, controllable, or 
certain. The time during which both the faradic and the gal- 
vanic current were considered far-reaching and omnipotent 
remedies has long gone by. Indeed, there are those, particu- 
larly among neurological specialists, who, while maintaining 
that the currents are great aids for diagnostic purposes, yet 
reject their claims as curative agents. But lately Meltzer — in 
a paper read before the Association of American Physicians — 



314 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

has proved the total absence of efficacy on the part of the elec- 
trical current when applied to the mucous membrane of the 
stomach and the intestines. It is to be hoped that the exer- 
tions of the American Electro-Therapeutic Society will clear 
up many doubts and obtain results commensurate with the en- 
thusiasm which gave rise to its foundation. 

Franklinism, once the only recognized electrical remedy, has 
rapidly regained a standing, much of which is due to Dr. W. J. 
Morton, of New York. But neither the common disruptive 
discharges which he uses in locomotor ataxia nor his "static 
induced currents," obtained by adding condensers to the static 
machine, will find many applications among children affected 
with diseases of the nervous system. 

The effect of the electrical and the galvanic current is per- 
haps best exhibited in cases of peripherous nervous affections. 
Paralysis of the facial nerve and of the brachial plexus, both 
not infrequent after difficult or clumsy deliveries, are among 
those in which the current is frequently used; its effect is mostly 
very slow, sometimes not very satisfactory. Particularly in 
cases of facial paralysis, where the reaction of degeneration has 
already been established, it leaves much to be desired. The 
paralysis of the brachial plexus *of the newly-born, as it depends 
on stretching, laceration, or hemorrhage, and is sometimes com- 
plicated with injuries to one or more of the joints of the upper 
extremity, — in the lower joints the affection is but rarely ob- 
served, — allows a doubtful prognosis only. It concerns mostly 
the fifth, sixth, and seventh lower cervical nerves, which form 
the posterior cords of the brachial plexus. In that case the 
deltoid, biceps, brachialis internus, coracobrachialis, infra- 
spinatus, and sometimes the exterior muscles of the hand are 
affected. When the inner cords are involved, the whole ex- 
tremity is paralyzed, and will be shortened and atrophic. Some 
of the cases, however, are distinctly the results of an intersti- 
tial inflammation and consecutive hyperplasia of the connective 
tissue of the nerve-fibres. In such, no matter whether on the 



DISEASES OF THE NERVOUS SYSTEM. 315 

basis of syphilis or not, the interstitial hypertrophy should be 
fought with mercurials or iodides or both. The same must be 
said of polyneuritis, — such as follows infectious diseases, with 
its pain and increasing paralysis and degeneration, together 
with intact bladder and pupils, — in which rest, salicylate of 
sodium, and, later, strychnine yield better results than does the 
current. Nor is it more effective in hemicrania, no matter 
whether it be the result of congenital disposition, or compli- 
cated with hysteria and epilepsy, or dependent on anaemia, 
hypermetropia, dyspepsia, overwork, or confined air. In all 
these conditions the correction of the causes, a convex glass, 
country air, shortening of school hours, cold-water treatment, 
arsenic, iron, and aconitia, with an occasional dose of a bro- 
mide, will yield better results. 

To complete what I have to say on the subject of the reme- 
dial influence of electricity and galvanism, I may as well speak 
here of their employment in the peculiar changes of the 
muscles which are known under the heads of muscular atrophy, 
progressive juvenile muscular dystrophy, and pseudo-hyper- 
trophy. All of these names are applied to abnormal conditions 
whose coarse anatomical changes are better understood than 
their causes. As long as these are unknown we cannot help 
admitting that therapeutical experiments, such as those with 
thymus gland in pseudo-hypertrophy, be they ever so tentative, 
are justified. In a certain percentage (exactly as in Thomsen's 
congenital myotony) the alteration is in the beginning strictly 
local or confined to muscular tissue; in others there can hardly 
be a doubt as to the cerebral origin of the muscular anomaly. 
In all of them electricity and galvanism have been extensively 
used, together with massage, bathing, etc., but in no case have 
their effects been noteworthy. As in many other cases 
where the original cause (or change ?) is inflammatory, and ex- 
hibits itself in proliferation of cellular interstitial tissue (no 
matter what its final result is destined to be), mercury, mostly 
the bichloride, — administered patiently and watched carefully, 



316 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

— appears to have given me better results. At least, the prog- 
ress seemed to be slower and intermissions of the morbid pro- 
cess more distinct and prolonged. 

2. Operations. 

Operations on the skull and brain are among the prides of 
modern operative surgery. Escapes from death on the table are 
more numerous than formerly, and recoveries from diseases 
formerly fatal, because permitted to die without an operation, 
are not unheard of. Craniotomy has been performed for in- 
juries, intra- and extra-dural hemorrhages, hydrocephalus, 
softening, tumors and cysts, Jacksonian epilepsy, athetosis, 
chronic contractures, certain mental diseases, otherwise in- 
curable headaches, old cicatrices, and abscesses. Infants and 
children come in for their share, mainly with abscesses, 
hemorrhages, hydrocephalus, Jacksonian epilepsy, and prema- 
ture ossification of the cranial bones and fontanelles, with epi- 
lepsy and idiocy among its results. So far as craniotomy and 
craniectomy are concerned in cases of microcephalics or idiocy, 
no other surgeon has met with the favorable results alleged to 
have been obtained by Lannelongue. Guided by thirty-three 
cases of American surgeons, — fourteen of which died soon, 
while nineteen only recovered from the operation, and very few 
showed any improvement, — I treated of the subject in my ad- 
dress before the Eleventh International Medical Congress at 
Rome, April, 1894,* and arrived at the following conclusions: 
that congenital idiocy is the result of many different forms of 
arrest of development (of blood-vessels, cortex, island of Reil, 
hemispheres), of inflammations (meninges, encephalon, with 
softening, or sclerosis), of thrombosis, and of hemorrhages; 
that it is a frequent result of microcephalus, which, as a rule, 
is not dependent on premature ossification of the bones and 
fontanelles, but in the large majority of cases on arrest of de- 

* "Non nocere," New York Medical Record, May 19, 1894. 



DISEASES OF THE NERVOUS SYSTEM. 317 

velopment of some parts of the brain, mostly connected with 
long-continued patency of the fontanelles; that, therefore, oper- 
ations undertaken to widen the cranial cavity are of no use, 
for a brain which did not grow before the cranium closed will 
not grow afterwards, and absent or defective parts will not 
develop; that even cases with a clear history of premature 
ossification are not, or very doubtfully, benefited; that, finally, 
the operation undertaken for the purpose of enlarging the 
cranial cavity has the opposite effect, as is proved by the ex- 
perience of Van der Veer and Hun, also by a case reported 
and drawn by Bourneville, and, finally, by the skull, belonging 
to B. Sachs, of a child operated upon twice in the course of 
sixty-seven days by A. Gerster. It exhibits a mass of hard 
tissue proliferating into the cranial cavity along the whole 
wound made in the first operation. I trust, therefore, that the 
days of uncalled-for craniotomy and craniectomy are numbered. 
At the present time Bourneville {Prog. Med., 1897, p. 390) 
favors craniectomy for idiocy in cases of trauma, abscess, or 
tumor only. 

Starr collected, in 1889, a total of 270 brain tumors in chil- 
dren. Of these, 152 were tubercles, 37 gliomata, 34 sarcomata, 
5 gliosarcomata, 30 echinococci, cysticerci, and cysts, 10 
carcinomata, and 2 gummata. The carcinomata were mostly 
secondary, the gliomata and sarcomata primary. Forty of the 
two hundred and seventy were superficial, and in sixteen of the 
forty their localities could be distinctly diagnosticated. There- 
fore, trephining and operations on the substance of the brain 
for tumors will never be numerous. Their diagnosis is not 
always easily made, and that of the locality affected is l>eset, for 
the present, with still more difficulty. Gliomata are but rarely 
near the surface; solitary tubercles are sometimes found in the 
gray substance of the brain, but more frequently in the corpora 
striata or thalami optici. In many more instances an operation 
will be required because of tumors originating in the cranium 
or its periosteum and encroaching upon the brain; they are 



318 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

mostly sarcomata, fibro-sarcomata, or osteomata. One of the 
last mentioned I have removed. A cyst of the dura mater, re- 
sulting from hemorrhage, was successfully removed in the ser- 
vice of Dr. Henry Hun, at Albany, followed by marked im- 
provement of the child's idiocy and convulsibility. 

Starr is rather favorably inclined towards trepanation in a 
number of cerebral diseases; it is true that those which promise 
no success from medical treatment cannot lose by surgical in- 
terference. In such cases of hemorrhage as permit of a local- 
ized diagnosis, though that between an extra- or intra-dural 
situation may be impossible in many instances, he favors it. 
His advice of tentative interference with "microcephalus" I do 
not look upon favorably. Abscesses, unless they be the results 
of pulmonary gangrene, typhoid fever, or pyasmia, if their loca- 
tion can be determined upon, and be accessible, are to be oper- 
ated upon; the opening must be sufficiently large to permit of 
examination, and draining should be both extensive and pro- 
longed until granulation and complete recovery can take place. 
Tumors are not often the subjects of operation in children. It 
is true many are met with in infancy and childhood; accord- 
ing to Gowers two-thirds of all the cases of intracranial tumors 
occur in the first two decades of life. But those occurring 
in early life are mostly found in the cerebellum, the basal 
ganglia, capsula interna, corpora quadrigemina, pedunculi, 
pons, and medulla oblongata; very few such will ever be acces- 
sible to an operation. 

3. Inflammatory and Exudative Processes. Arrest of 
Development. 
The simplest form of cerebral meningitis is that which results 
from insolation and mental emotions and exertions. Frights 
(especially protracted fears) and overstudy are frequent causes. 
So is trauma, which, however, is liable to produce the puru- 
lent form. In pneumonia, particularly of the upper lobes, it is 
not uncommon; less frequent in typhoid fever, more so in 



DISEASES OF THE NERVOUS SYSTEM. 319 

the septic diseases of the newly-born, where, however, it is 
liable to form part of the general pyaemic condition. With 
the exception of the latter, where death is certain, an anti- 
phlogistic course of treatment is indicated here, if anywhere. 
The hair should be cropped short; the head must rest on a 
cool pillow and be placed high. Calomel at first in purgative, 
later in smaller doses. As the mercurial treatment is to be 
continued, a solution of potassic chlorate may be applied fre- 
quently to the gums and mouth. The heat of the head and the 
local inflammation must be fought by cautious cold applica- 
tions, according to the directions given formerly (p. 102), and 
by leeches applied to the nasal septum or to the mastoid pro- 
cesses, also by cupping to the neck and shoulders; coma by cold 
affusions to the head and hot bathing, with or without mustard, 
of the rest of the body. Great restlessness, sleeplessness, and 
general excitability demand warm bathing, bromides in gener- 
ous doses, from one to ten grammes (fifteen to one hundred 
and fifty grains) a day, chloral, and codeine. After the first 
invasion and the period of high fever have been successfully 
dealt with by calomel and a few large, afterwards moderate, 
doses of digitalis, the time for iodide of potassium (one to five 
grammes daily) has arrived, also for vesicatories to the neck 
and behind the ears. In regard to the latter, however, it is 
always well to be careful, for cantharides are the sworn enemies 
of the kidneys. The iodides must be continued a long time. 
Of the roborants to be given during convalescence, iron ought 
to be the last one selected. Lumbar puncture will be discussed 
shortly. 

It is not always easy to diagnosticate between a fully-devel- 
oped meningitis and a hyperemia resulting from similar causes, 
— viz., overexertion, emotion, insolation, and the continued 
effect of overheating and stimulating diet. The continuation 
of the treatment depends on the persistence of the symptoms. 
Quite frequently a warm or hot mustard bath, with temporary 
applications of ice to the head, repeated hot foot-baths, sin- 



320 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

apisms to the neck, an erect posture in bed, a calomel purga- 
tive (with or without local depletion), and occasional counter- 
irritation by derivant enemata (vinegar 1, water 5-6) will suf- 
fice. The passive hyperemia, however, complicated with and 
depending on general and local cerebral ancemia (occasionally- 
even thrombosis of small vessels) and that which is caused by 
the rapid inanition produced by the different forms of acute 
and exhausting intestinal discharges require an altogether dif- 
ferent treatment. In place of the antiphlogistic treatment, 
stimulation is indicated. Still, caffeine and alcohol are to be 
avoided during the worst stage; camphor, ammonium car- 
bonate, and musk will answer better. Food and medicines 
are to be regulated by the requirements of follicular or other 
enteritis, and water must be supplied in ample quantities. 
When, however, there is vomiting and when diarrhoea is per- 
sistent, neither the stomach nor the rectum will accept it. In 
these cases the only salvation may be in copious (pint or quart) 
subcutaneous infusions of warm and sterilized salt-water solu- 
tion (water 1000, table salt 6-7, with or without sodium car- 
bonate 10-12). 

Thromboses from other causes are treated on the same prin- 
ciples. Debility and paralysis require such stimulants and irri- 
tants as the brain will tolerate. Embolisms, with their secon- 
dary conditions of irritation and inflammation, should be 
treated according to the rules detailed above, and will require 
ice, purgatives, warm bathing, and iodides, with or without 
bromides. The resultant paralysis demands massage, elec- 
tricity, strychnine, and mineral baths such as St. Catherine or 
Kreuznach. Chronic remnants of an inflammatory disorder, 
no matter from what cause, may be benefited, even after a long 
time, by a protracted course of treatment with iodide of potas- 
sium, or with mercurials, or both together, or alternating. 

Ergot is useless in these cases of intracranial hyperemia; 
it does not have the favorable effect which often follows its use 
in similar changes in the spinal canal. 



DISEASES OF THE NEBYOUS SYSTEM. 321 

Tubercular meningitis is not always fatal, though the diag- 
nosis permit of no doubt. The latter, however, is mostly made 
at a time when the prognosis is very ominous. Biedert had an 
opportunity to make an autopsy on a patient treated for tuber- 
cular meningitis, death resulting from another disease. He 
found old meningeal tubercles. Still, many of the recoveries 
reported — mainly for the purpose of proving the efficacy of 
specific treatments (tartar emetic and iodoform ointments, etc.) 
— are of doubtful character. I also have seen recoveries from 
what I diagnosticated as tubercular meningitis. One died after- 
wards of necrosis of the cranial bones, occasioned by my tartar 
emetic ointment. Another case, that recovered thirty years ago, 
is still alive in an insane asylum; he has never been normal, 
mentally, since I discharged him "cured." From what little I 
have said it is evident that a preventive treatment only may be 
expected to do good, if anything will. Infants and children of 
scrofulous or tuberculous families should be brought up with 
unusual care. Congestion of the brain, caused by feather pil- 
lows, exposure to the sun, hot rooms, coffee, tea, and alcohol, 
physical and mental overexertion, must be guarded against. 
Constipation must be overcome. Eczema and other eruptions 
of the surface should be slowly healed, but they must be healed. 
Their presence is a constant source of danger, both by reason 
of the opportunities afforded for a direct invasion of microbes, 
and of the irritation and swelling of lymph-bodies. These, 
when found, must be removed by internal treatment, massage, 
ointments (green soap, iodide-lanolin mixtures), or enucleation. 
Nasal catarrh should be immediately relieved; adenoid growths 
in the naso-pharynx, either regularly irrigated or when they are 
large, removed. Their persistence is a cause of "scrofulous 
glands" and, possibly, of secondary tuberculosis; also of direct 
invasion of germs through the patent orifices of the lymph- 
vessels at the base of the cranium and the extra-dural tissue. 
The best general preventive treatment of infants and children 
with a predisposition to tubercular meningitis, rendered proba- 

21 



322 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

ble by hereditary taint and by suspicious symptoms, consists, 
in my opinion, in the regulation of the diet and hygiene: ani- 
mal food mostly, daily cool or cold bathing with vigorous fric- 
tion, open windows, exercise, cod-liver oil during the cool and 
cold months, arsenic in regular small doses, and pure guaiacol 
(or the carbonate of guaiacol) for many months in succession 
through a course of years, besides a'ttention to the nares and 
adenoid growths. 

When the disease is fully recognized, constipation must be 
overcome; the first drug to be used for that purpose should be, 
or contain, calomel. It may be repeated from time to time, 
provided the regular use of iodide of potassium does not con- 
traindicate it for chemical reasons. The latter ought to be 
given in large doses through (nearly) the whole duration of the 
illness. Tubercular meningitis both permits and demands 
large doses, — from one to three drachms (five to twelve 
grammes) daily. Mercury is indicated. Calomel and iodide of 
potassium being incompatible, the bichloride should be given, 
or mercurial ointments used instead. Cardiac stimulants may 
be employed to advantage from the beginning, the circulation 
being defective on account of the undue irritation of the pneu- 
mogastric nerve. Strophanthus (and strychnine in very small 
doses) will probably act better than digitalis. Caffeine and 
alcohol must be carefully avoided. Chloral will act well when 
headache is severe and a tendency to convulsions exhibits itself. 
To combat the latter the inhalation of chloroform cannot be 
avoided; nor morphine altogether, when the pain is exces- 
sive. Antipyretics are not indicated in the beginning, when 
the temperature is low; during the last few days, when it rises 
previous to death, they are useless. With tartar emetic oint- 
ments applied on the closely shaved head I have had ample ex- 
perience, and shall not employ them again. My experience 
with iodoform ointments (1 : 5-10) is but small, and my confi- 
dence in their efficacy less. Vesicatories may do harm by an- 
noying and irritating the patients; I expect more derivative 



DISEASES OF THE NERYOUS SYSTEM. 323 

action from keeping the bowels open and the body sufficiently 
covered with clothing. Leeches are seldom useful, except 
when conjunctival injection and local heat of the head be- 
come apparent at an early date. Otherwise, symptomatic treat- 
ment is all that can be advised. Unusually severe vomiting in 
the beginning may require ice pills and mild doses of an opiate, 
or cocaine, perhaps tincture of iodine in one-quarter- to one- 
half-drop doses, or arsenous acid, one-three-hundredth to one- 
five-hundredth grain (J— J milligramme), from four to ten times 
a day. Ice applications are useless, for the temperature is low 
before the last stage sets in, the local hyperaemia mostly passive, 
and the tolerance of ice in small children easily exhausted. 

To what extent the operative treatment by trephining and 
draining will prove successful remains to be seen. There are 
but few cases of tubercular meningitis not complicated with 
general miliary tuberculosis; thus the prognosis of operative 
interference is not at all promising. Besides, the cranial can- 
not be compared with the peritoneal cavity, which is known to 
be favorably influenced by the performance of a laparotomy. 
Peritoneal tuberculosis is very apt to be isolated and uncom- 
plicated, its secreting surface of a different character, and 
drainage easier. Quincke, Fiirbringer, Caille, G. W. Jacoby, 
and many others since have tapped the spinal canal between 
the third and fourth lumbar vertebras. The operation of lum- 
bar puncture has resulted in facilitating a diagnosis in many 
instances, in temporarily relieving some symptoms, but never 
in a cure. 

In order to obtain any cerebro-spinal liquor from the cranial 
cavity, lumbar puncture should withdraw from ten to fifteen 
cubic centimetres. The total amount, however, should not 
exceed twenty or thirty at any one time. None may be ob- 
tained when the needle does not reach the spinal canal, or is 
obstructed by fibrin, or is caught between the nerve-fibres of 
the cauda equina, or when the connection between the ventri- 
cles and the cerebral and spinal subarachnoid spaces has been 



324 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

disturbed by exudative processes. The normal liquor, also that 
obtained in many pathological conditions, is clear, of 1007 
specific gravity, and 0.2-0.5 per mille albumin. Sugar is rarely 
found in connection with tumors. In simple serous meningitis, 
in chronic hydrocephalus, in that connected with pneumonia 
and other infectious diseases, also with uncomplicated tumors, 
the liquor was clear, in cerebro-spinal meningitis it was turbid, 
somewhat purulent, and contained pneumococci and meningo- 
cocci, in many cases (by no means all) of abscess pus, and strep- 
tococci and staphylococci, in tubercular meningitis mostly 
bacilli (Jacoby eleven times in seventeen cases), in apoplexies 
and hemorrhagic pachymeningitis blood. Kiliani and Jacoby 
found blood when the diagnosis of spinal hemorrhage had been 
made. 

The puncture, which never should amount to an aspiration 
because of pain in back, head, and neck which are caused by it 
(Fiirbringer), though not always successful as a means of diag- 
nosis, gives less satisfaction from the view of therapeutics. It 
gave some relief in meningitis, headaches (inclusive of the head- 
ache of chlorosis), delirium, and hyperesthesia., but they would 
return. In a few cases of cerebral lead symptoms, and in those 
connected with chlorosis, it is said to have given relief. Len- 
hartz improved a case of cerebral oedema connected with trau- 
matic injury. Altogether it is to be hoped that we are standing 
in the vestibule of a new achievement. 

General paresis ("periencephalitis" and other changes) is 
no exception to the rule that the pathological changes occur- 
ring in the brains of adults are also found in children. It is 
rare, however. In a few cases there seemed to be a hereditary 
disposition as in other cerebral alterations leading to chronic 
intellectual disorders. The vast majority of cases are of syphi- 
litic origin, and a thorough antisyphilitic treatment ought to 
have a favorable result, now and then. 

The prognosis in, and the results of treatment of, chronic 
hydrocephalus depend on its nature. When it is congenital, 



DISEASES OF THE NERVOUS SYSTEM. 325 

no matter whether internal or external, whether the result of a 
foetal inflammation or of an arrest of development, the morbid 
processes leading to it are so serious as to render the outcome 
of treatment — though it do not prove fatal — very problematic. 
Substantial changes of the original brain-substance cannot be 
remedied by the removal of fluid. Nor is it probable, or rather 
possible, that the cerebral atrophy produced by permanent 
intracerebral pressure can be overcome by attempts at relieving 
hydrocephalus. The chances are better when chronic hydro- 
cephalus is the result of a postnatal meningitis. But even in 
these cases, while the recoveries — I mean anatomical recoveries 
— from the secondary effusion are more numerous, the inflam- 
matory alterations both in meninges and brain are such as 
either to predispose to future meningitis, or to so alter both the 
physical and mental functions of the cranial contents as to 
render the result either very doubtful or far from desirable. 
Our prisons and lunatic and idiot asylums tell the tales. The 
chances of hydrocephalic patients are best when the disease is 
the result of chronic hyperemia, — for instance, in craniotabes. 
Such children with a slight amount of hydrocephalic effusion 
are always apt to get entirely well under proper antirhachitical 
treatment (fresh air, animal food, phosphorus, iron, etc.), and 
even large amounts of fluids are absorbable, with restitution of 
the brain and its functions, in a certain percentage of cases. 

After all, it is evident that iodides, mercurials, vesieatories, 
diaphoretics, diuretics, and purgatives are useless in congenital 
hydrocephalus. In the other forms the diagnostic and thera- 
peutical skill of the practitioner will make the required selec- 
tion, as far as indicated. Should the head grow rapidly, the 
prognosis is bad. In these cases even compression will do but 
little, inasmuch as compression of the increasing fluid, unless 
it can be removed, will also compress the brain. In less pro- 
gressive cases the application of rubber bandages or caps, also 
adhesive straps, may do some good. They should not be 
omitted in those cases which are punctured, provided the 



326 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

cranium is still compressible. Indeed, in almost all the cases 
on which it was performed the children were quite young 
and no ossification of the sutures had taken place. Therefore 
the case successfully operated upon by Helm, of Frankfort, 
Germany (with repeated punctures), — that of a girl of twelve 
years, presented (alive) before the German Congress for In- 
ternal Medicine of 1886,— may be considered very exceptional. 
Cases which require trephining before drainage can be estab- 
lished hold out no hope. 

Punctures of the hydrocephalic cranium were made in an- 
tiquity, but, like many other experiences of Hippocrates, were 
forgotten. It was not until this century that observations of 
recoveries were made after the intracranial fluids had found a 
spontaneous or traumatic outlet. Honing published a case 
(1828) of recovery after a complicated fracture of the frontal 
bones and a discharge extending over days; Greatgood (1828) 
one after an injury produced by a nail; Haase (1818) one of 
spontaneous perforation. Huguenin collected six cases of re- 
covery after a discharge through the nose (or ear) had been 
established. Punctures have been made in great numbers; 
many more, certainly, than have reached the eyes of the medi- 
cal public. It can, however, be easily understood that very 
probably not a single case of recovery has taken place but has 
been published. Indeed, the publications are mostly made 
very soon after the operation or operations were performed. 
Thus, when Beely collected twenty-seven cases of recovery 
after puncture (two of which were combined with tincture of 
iodine injections), he expressly stated that only eight of them 
had been under observation a year or more. Altogether, it 
may be more human than, unfortunately, scientific to pride 
oneself on one's results, particularly when these results speak 
of benefit to mankind. Thus, Conquest reports "ten cures" 
out of nineteen cases operated upon by himself. West, than 
whom there is no critic more learned, wise, and incorruptible, 
collected sixty-five cases with (alleged) "sixteen recoveries, ,, 



DISEASES OF THE NERVOUS SYSTEM. 327 

which he, however, reduced to from three to perhaps five. Bat- 
tersby came to the conclusion that probably there was one re- 
covery in fourteen cases on which the operation was performed. 
But from my previous remarks, referring to the severity 
of the original lesion and to the results of the fluid present 
either outside or inside the brain, it is easily understood that I 
cannot look upon the result of the operation as anything so 
favorable as is claimed. Still, there are many cases in which 
it must not be omitted, together with general treatment. I 
have made a number of lumbar punctures for the same purpose, 
with the visible effects on the distended fontanelles and sutures, 
but without a cure. Among the remedies I value most highly 
here or wherever tissue-building is a main object, is phosphorus. 
It may be alternated or combined with iodides, digitalis, iron, 
or arsenic, according to circumstances. 

The puncture should be made over the large f ontanelle, about 
one centimetre or more (half an inch) from the median line; 
vertical when the lateral ventricle is to be reached, oblique 
when the hydrocephalus is external. It is best not to remove 
much fluid the first time; from twenty to twenty-five cubic 
centimetres (5-6 drachms) will suffice. As a rule, there is but 
little reaction, and the operation may be repeated within a few 
days or a week. During the operation and after it compression 
must be made to prevent hyperemia, hemorrhage, and rapid 
re-effusion. In cases of external hydrocephalus a mild injec- 
tion of iodine with iodide of potassium and water ("Lugol"), 
may be made to suppress secretion. It will take very numerous 
observations, however, during many future years to determine 
to what extent all these attempts at suppressing secretion and 
at facilitating meningeal adhesions and reproduction of brain 
are to be considered valuable in the interest of families or of 
mankind in general. When the percentage of albumin con- 
tained in the aspirated fluid increases after every operation, the 
prognosis is bad. 

A number of chronic degenerations of the brain, both gen- 



328 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

eral and local, are the result of inflammatory processes. If 
they be prenatal, the prognosis is very bad; if acquired 
after birth, the nearer the beginning of treatment to their 
starting the better the possible result. Such conditions are 
disseminated sclerosis, also the infantile spastic hemiplegia de- 
pending on encephalitis, and oulbar paralysis. The general 
indications for treatment are the same. In acute exacerbations, 
depletion, ice, and laxatives will be required; bulbar paralysis 
may often demand a local application of ice to the nape of the 
neck. The chronic condition, with fibrillary twitchings, elec- 
trical changes, and absence of reflexes, requires the different 
forms of electrical and galvanic treatment, iodides, mercurials, 
and warm bathing. In all such cases the indications are pro- 
nounced enough, but the results mostly negative. 

Meningocele and encephalocele (hernia of the brain) are but 
rarely amenable to a successful treatment. When they are 
small, the protruding contents may be retained by a properly 
fitting appliance of lead or leather or rubber, until the abnor- 
mal aperture has had time to close. This process may be accel- 
erated by the administration of phosphorus (ol. phosphoratum 
or elixir phosphori), of which the newly-born may take at the 
rate of one-third of a milligramme daily (one one-hundred-and- 
eightieth grain). When larger and irreducible, the tumefaction 
has been caught in a clamp and punctured, or removed alto- 
gether. In some cases the clamp was allowed to remain, in 
others it was removed; in the latter the wound was sutured. 
The complication with hydrocephalus impairs the prognosis. 
Similar treatment has been resorted to in a few cases of menin- 
gocele spuria, which results under an intact scalp from fis- 
sures of the cranium to which in infancy the dura mater is 
tightly adherent, induced by forceps operation, by fall or some 
other trauma, by caries, or by syphilis. 

There are complications of grave nature. When the brain is 
injured down to a lateral ventricle the gap may become per- 
manent and cause porencephalus. Ehachitis, and the interpo- 



DISEASES OF THE NERVOUS SYSTEM. 329 

sition of brain substance between the fractured bone, prevents 
spontaneous recovery. Indeed, it appears that the fracture 
never heals spontaneously; practically, the fissure may close by 
the interposition of the thickened membranes and aponeurosis, 
together with diminution of the cerebro-spinal liquor. Such 
an apparent recovery may, however, not always be a blessing, 
for epilepsy and metastatic meningitis have been observed 
afterwards. Eecent cases may be treated by the elevation of 
depressed bone and bone suture. In incipient spontaneous im- 
provement, in fact in stationary cases also, the tumefaction 
should be protected by a pad. Iodine injections have been 
made into the cavity, which contains cerebro-spinal liquor only, 
with occasional success; and in a few cases of epilepsy, and of 
rhachitical hydrocephalus, the lateral ventricles were drained. 

4. Psychical Diseases. 
Psychical diseases have been believed to be rare in infants 
and children. The statistics published by lunatic asylums and 
by specialists are meant to prove that. These statistics are cor- 
rect, but the conclusions drawn from them are not so. Every 
practitioner knows better. Dementia and mania are by no 
means rare at any period of infancy and childhood, melan- 
cholia often without delusions, and with suicidal tendency, and 
similar conditions of depression are not quite so frequent; they 
are more generally found before and about puberty. The pub- 
lic institutions do not contain such patients. A demented or 
even a maniacal child is managed and prevented from doing 
harm to itself or to others, at home and by the family, better 
than an adult, and it is there that numerous such patients can 
be observed. The same forms of mental disease occurring in 
the adult are also seen in the young. Besides those which have 
been mentioned, we meet with moral insanity (often character- 
ized merely as motor and psychical restlessness, or incorrigible 
conduct), monomania, epileptic and circular dementia, even 
"paresis" and delirium tremens. More frequent than either 



330 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

or all of them are idiocy and cretinism, the former of which is 
a not rare final termination of mental anomaly in the adult, 
while in the young it is among the first appearance of aberra- 
tion, though, indeed, but the result of ever so many different 
anatomical changes. Here also heredity is one of the factors. 
A peculiar form of family idiocy, generally fatal, and associated 
with early blindness, was described by B. Sachs. One such case, 
complicated with rhachitis and with atrophy of the optic nerve, 
was reported by H. Heiman, another by Koplik. Their varieties 
I have discussed above, also the possibilities of treating them 
medicinally or by surgical procedures (p. 316). Cretinism has 
some well-understood anatomical peculiarities or causes; promi- 
nent among them are the shortening of the cranial base by 
premature ossification of the occipito-sphenoidal synchondrosis 
and, it appears (principally), the absence or degeneration of the 
thyreoid gland. Thus, the cretinism of the foetus and infant 
and the myxcedema of the adult are among the results of the 
same anomaly. 

My object in enumerating most of the possible causes of men- 
tal disorders in the young is principally to show that preven- 
tive treatment should be considered more reliable than curative. 
Heredity plays an important role, so does inebriety and all other 
forms of psychical aberration or serious nervous disorders, — 
epilepsy, diabetes. To what extent matrimony between rela- 
tives contributes to mental disease in the offspring is by no 
means proven. I cannot, from theoretical reasoning and from 
practical experience, admit that two healthy persons, be they 
ever so nearly related, will for that reason have a diseased child. 
But to what extent the state of the future will interfere with 
the marriages of insane and epileptic people, as also with those 
of carcinomatous or tuberculous patients, provided our thera- 
peutics continues to be as unsatisfactory as hitherto, remains to 
be seen. It is but natural that the rapid favorable changes of 
the last few years in our therapeutics, both internal and ex- 
ternal, should increase our hopes in regard to great results. 



DISEASES OF THE NERVOUS SYSTEM. 331 

Diseases of the foetus, mostly of inflammatory character, — 
meningitis, encephalitis, — predispose to mental disorders. 
During birth, a prolonged labor or undue pressure by pelvis 
or forceps invites hemorrhage with its results. Spontaneous 
hemorrhages are the more common and the more dangerous 
the younger the infant. Congestions and inflammation of the 
meninges or of the brain are frequent in the infant and child. 
Their causes are rhachitis of the cranium, insolation, hot stoves 
and bed-pillows, tumors, stimulants, such as coffee, tea, and 
alcohol, falls and blows, and diseases of the heart. Disorders 
of the ears are frequent, and affections of the nose not unheard 
of, causes of intracranial disease. Infectious diseases, such as 
typhoid, scarlatina, erysipelas, rheumatism, influenza, are 
known to be direct causes of mental disturbance in the young. 
The removal of intestinal worms has ended a psychical disorder. 
I have known overexertion at school to result in mental aber- 
ration, which terminated either in recovery or in death from 
exhaustion or meningitis. The period of puberty, with its sud- 
den changes, creates a predisposition, and excessive masturba- 
tion may cause derangement. Bad habits, bad training, and 
congenital migraine add oil to the fire. 

This cursory enumeration of causes gives plenty of food for 
thought. The conscientious family physician with a number 
of infants and children under his charge has a great responsi- 
bility. His cares ought to begin with conception. Many a case 
of infant meningitis (hydrocephalus) can be prevented by 
timely attention to the mother. Labor must not be permitted 
to last too long, asphyxia in the newly-born must be imme- 
diately attended to, and strict care should be taken of the diet 
and hygiene of the baby. Errors in this respect are not pun- 
ished immediately; and while some babies thrive, or appear to 
thrive, while mistakes are being constantly made, in others the 
foundations are being slowly laid for ill health and serious dis- 
ease, both physical and mental. That heart and ears ought to 
be attended to in time, and persistently, is self -understood; but 



332 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

procrastination — waiting for better times and "second denti- 
tion" and "puberty" — is too common an occurrence. Perhaps 
the greatest negligence on the part of medical men is exhibited 
in regard to mental overwork. Our schools have become hot- 
houses in which scoliosis, near-sightedness, anaemia, neuras- 
thenia, chlorosis, and cerebral exhaustion and disease are being 
bred in incredible numbers. If the children are sent to school 
at six or seven years of age, it should not be forgotten that 
their brains cannot endure constant work without getting ex- 
hausted and injured. Between the sixth and ninth year per- 
sistent exertion, the teaching unit, should not last more than 
twenty or twenty-five minutes of every hour, between the ninth 
and twelfth year thirty or thirty-five, after the twelfth year 
forty minutes. For the first class two or three, for the second 
three or four, for the third four or five hours is all that should 
be enforced. Short learning units permit earnest work and 
progress, long ones cause drudging labor and dangerous fatigue. 
The apparent offset to this mental overwork — gymnastic or 
"calisthenic" exercise in the same building, as part of the cur- 
riculum — adds to the general exhaustion. It is time that the 
medical profession looked into the increasing degeneration of 
the people resulting from this overstraining of the young brain, 
ninety per cent, of the growth of which is not attained until the 
seventh year, and the full growth not reached before the four- 
teenth or seventeenth. Physicians will do well to be no longer 
afraid of the charge of going into politics. If they do not wish 
to be "politicians," let them be something better, — statesmen. 

The general remarks made on the first pages of this chapter 
will suffice for both the general and causal treatment. Serious 
and unmanageable cases belong to an institution. Conditions 
of excitement, besides proper hygienic and dietetic treatment, 
require rest in bed, warm bathing (not hot), and plenty of sleep, 
which may safely be procured by opiates (extractum opii, 
codeia), or hyoscin, chloral, sulphonal, amylene hydrate. 

In the treatment of psychical disorders it is easy to do too 



DISEASES OF THE NERYOUS SYSTEM. 333 

little or too much. As long as our lunatic asylums are (were ?) 
only more or less genteel prisons, and wherever the "superin- 
tendents" are more custodians than physicians, where records 
are kept slovenly, and no autopsies made, nothing whatever 
is (was ?) done to relieve the physical basis of intellectual dis- 
orders. Whenever that is sought for, and found with more or 
less certainty, the indications for treatment are self-evident. 
Overdoing, however, is as bad as underdoing. Hypnotism 
should not play a prominent part in the therapeutics of the 
nervous system. Its utility is doubtful, its dangers as great as 
those connected with all sorts of psychological experiments gen- 
erally. Autosuggestion is very active in neurasthenics and 
hysterical persons, also in the young, who, even when in 
average health, are imaginative, unreasoning, credulous, and 
impulsive. 

Mild forms of temporary mental aberration are the night- 
terrors (pavor nocturnus). They are mostly (not always) met 
with in delicate, pale, scrofulous, or rhachitical children, with 
neuropathic tendencies somewhere in the family. Like attacks 
of genuine dementia or mania, they are not remembered by the 
patients. But few of them are attended by fever; many result 
from or are connected with digestive disorders, nasal polypi, 
adenoid growths, or hypertrophic tonsils. They should be 
attended to. Heavy meals must be avoided, also emotions, 
frights, ghost-stories, exciting games; the attacks are often 
connected with reminiscences. The bowels should be kept re- 
laxed. A dose of quinia bromide or potassium bromide at bed- 
time and a room not absolutely dark are good preventives. 

5. Spinal Inflammations, Genuine and Infectious, and Arrests 
of Development. 
The general rules for the treatment of diseases of the organs 
contained in the spinal canal are almost identical with those 
detailed in reference to the brain and meninges. With the ex- 
ception of rare cases of pseudoplasm, the changes occurring in 



334 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

the spinal cord and its meninges depend on anomalies of the 
circulation, or on some form of inflammatory process, either in 
an acute or a chronic state. To the latter class belong the final 
and persistent lesions of spinal pachymeningitis and leptomenin- 
gitis, transverse myelitis, poliomyelitis, lateral and amyotrophic 
lateral sclerosis, paramyoclonus, and tabes. Multiple dissem- 
inated sclerosis, with its, at first, slight tremor in voluntary 
movements, which may be the only symptom for years, and is 
followed by nystagmus, optic atrophy, scanning speech, and 
tendon- jerks, appears to me mostly localized in the spinal cord, 
in children. Before entering upon a course of treatment, it is 
of the greatest importance to study the etiology of an individual 
case; a disease of the bone, or tuberculosis, or syphilis must be 
known before it can be effectually treated. Nor is it super- 
fluous to omit the exact diagnosis of those ailments which are 
more and more supposed to be of an infectious nature and of 
bacteric origin, such as Landry's paralysis and poliomyelitis; 
for the time may come, even during our lives, when an exten- 
sive anti-infectious, antibacteric, antitoxic treatment or preven- 
tive immunization will be among the modern therapeutics of 
many apparently unmanageable diseases. 

In every case of acute disease of the spinal cord or its 
meninges absolute rest is required. But the patient, to avoid 
overheating and hypostasis, must not be kept on his back con- 
stantly, or most of the time, and not on feather-beds or pillows. 
Quilts covered with linen or cotton sheets, air-mattresses, or 
water-beds are often absolute necessities. When the acute 
disease can be localized, as mostly it can, cold water, ice-water, 
the ice-bag, with now and then an ether spray, or local deple- 
tion by cups or leeches, are indicated. Yesicatories or the tinc- 
ture of iodine ought to be avoided in this stage, because of their 
irritating and annoying effects. Purgatives are required on 
general principles, — calomel (and) or salines. Now and then 
a mustard bath, quite hot, will act well as a derivant. The in- 
dications for digitalis (or other heart regulators and invigora- 



DISEASES OF THE NEEVOUS SYSTEM. 335 

tors) are frequent; direct antipyretics are seldom required. 
Quinine acts better here than in diseases of the brain, where it 
appears to give rise to occasional congestions. To influence the 
spinal circulation in acute and subacute diseases, ergot (useless 
in cerebral diseases) holds a high rank; the fluid extract may be 
given in doses amounting for the day to from one to eight or 
ten grammes in the beginning, later less, according to age. Its 
indication does not cease until the stage of chronicity, with 
anasmia, contraction, and incipient atrophy of the blood-vessels. 
Iodide of potassium is indicated early on account of its influ- 
ence on the circulation, and later for its absorbent effect. The 
difficulty in handling very old cases is due to the permanency 
of the local lesions which result from the solidification and 
cicatrization of the new cell proliferations. Nor are the dif- 
ficulties in this respect any less, with the exception of some 
syphilitic cases, in regard to mercury. The sooner and the 
more persistently these remedies are employed, either internally 
or externally, either simultaneously or alternatively, the 
better will be their gradual effect. The bugbear of saliva- 
tion is no longer feared, since it has become more widely known 
that the younger the patient the better will he bear mercury. 
Galvanism and the electro-magnetic current are used on general 
principles, as mentioned before. Neither should be employed 
at an early stage. The former requires large electrodes, well 
salted, to reach the cord; the direction of the current does not 
appear to make much, if any, difference. Sessions of from six 
to ten minutes, the current being inverted once or twice during 
that time, once or twice daily, are all that is demanded. The 
interrupted current is employed later to stimulate the muscular 
action, and should be used locally with small or more generally 
with large electrodes, or in the bath. Anaesthesia may require 
the application of the metal brush. Warm bathing is often at- 
tended by very good effects, due to its influence on circulation 
and the surface temperature. A bath may last minutes or 
hours; the latter mainly in secondary contractures, which may 



336 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

also require tenotomies. In these cases hot sand-baths have 
been used extensively in Europe, particularly where the fear of 
water has not yet begun to wane from the minds of the masses. 
Their usefulness consists mainly in the invariability of their 
temperature, which requires less attention and watching than a 
warm- water bath. In chronic cases ointments have been exten- 
sively used. Still, very few substances can be rubbed through 
the epidermis and cutis; indeed, hardly any except iodide of 
potassium (in glycerin, better still in lanolin) and mercury 
(ointment and oleate). Its application to the spinal column is 
of no advantage; it is better to select the usual places where 
the skin is thin and the lymphatics are near and numerous, — 
viz., the inner aspect of the extremities. Over the spine the 
actual cautery has also been found beneficial, together with the 
mineral springs containing salts and iodine (St. Catherine, 
Kreuznach, Oeynhausen, Nauheim). 

In many both of the acute and the chronic cases a sympto- 
matic treatment cannot be avoided. Pain must be lulled. Now 
and then the anode (positive pole) of a mild galvanic current 
will have some such effect; sometimes the local application of 
chloroform ointments or chloroform vapor in cotton, an ether 
spray, a menthol stick, or menthol in a ten-per-cent. alcoholic 
solution will do good. If not, hyoscine, chloral hydrate, croton 
chloral hydrate, opiates (internally or subcutaneously), or hot 
fomentations are required; for there is no greater enemy of 
the sick than pain, and no greater bliss and gain than rest. 
Other symptomatic treatment may be required for the motory 
and trophic paralyses resulting from a number of spinal- 
cord diseases, such as paralysis of the bladder, of the intes- 
tines, of the sphincters, and bed-sores. The latter are very 
ominous, and the ointments of bismuth, or tannin, or balsam of 
Peru, though they be indicated and locally useful, will not 
defer very long the final termination. Paralysis of the bladder 
is said to be benefited by local internal electrization; it is bene- 
fited by ice-cold injections; its secondary cystitis is certainly 



DISEASES OF THE NERVOUS SYSTEM. 337 

improved by plain or medicated warm irrigation. Paralytic 
constipation requires physostigma and regular enemata. All 
of these forms of paralysis will be more benefited by the subcu- 
taneous than by the internal administration of the sulphate of 
strychnine. 

Suspension has been practised for several years in some of 
the chronic diseases of the spinal cord, mainly in tabes, which, 
fortunately, is rare among children. It may again become 
fashionable in another generation. Operative stretching of 
nerves is occasionally useful in contractures depending on cica- 
trization, as also in some neuralgias of adults. 

Acute poliomyelitis (spinal, essential, "dental" (!), infantile 
paralysis), as the initial stage may differ both in its onset and 
in its symptoms, may require different measures at first. Some 
cases exhibit a high fever, great excitement and prostration, 
even cerebral symptoms. The majority, however, come on sud- 
denly, without fever and without premonitory symptoms. The 
former class requires antipyretics and the necessary attention 
to cerebral and other urgent symptoms; much more can hardly 
be done, because in most cases of this class the diagnosis will 
probably not be made at first, with the exception of those in 
which it is assured by local pain and the observation of paraly- 
sis. These latter are the cases in which local applications of 
ice may prove beneficial. 

Every case, whether feverish or afebrile, requires absolute 
rest. The few which are suspected of originating in rheu- 
matism, or those which are complicated with peripheral neu- 
ritis, should be treated by salicylates, and locally by warm ap- 
plications or fomentations. All the rest will do better with 
cold applications — ice-water, ice-bag, cold water — continued 
for some time, but with interruptions. Depletion by means of 
leeches, or by cupping, is often indicated, particularly in such 
cases as exhibit local pain. I feel certain that a purgative in 
the beginning (calomel, salines) will do good; so will ergot; 
the equivalent of from one to three grammes or more may be 

22 



338 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

given daily, either as extractum ergotae or as extractum ergotse 
fluidum. It may be accompanied by a few drops of the tinc- 
ture of belladonna. As early as possible — that is, as soon as the 
necessity of absolute rest will permit of inunctions being made 
— mercurial ointment (on the first day or days the oleate) may 
be used, and the internal administration of iodide of potassium 
commenced at once. Both may be continued — particularly the 
latter — for several weeks; the dose should be smaller than in 
cerebral meningitis, half a gramme to one gramme daily being 
sufficient. Tincture of iodine modified by the addition of alco- 
hol, or sinapisms frequently applied for a few minutes at a 
time, may be used with advantage. 

The rapid improvement during the first week after the onset 
of the disease, and the slow convalescence of the few months 
before the residual (mostly local) paralysis becomes imal, hav- 
ing been established, the indications for treatment will change. 
Congestion and dilatation of blood-vessels give way to anaemia 
and contraction, and in place of belladonna and ergot, strych- 
nine must be given; at first, perhaps, internally. It may be 
beneficial when so administered, but hypodermically it will act 
better. I cannot agree with Gowers, who claims that it is prob- 
ably "never either necessary or desirable to give it by hypo- 
dermic injection in this disease/'* Several times a day, for 
weeks in succession, the cold shower-bath applied one or two 
minutes to the back, followed by lively friction, will contribute 
to the stimulation of the spinal circulation. 

The rapid waste of the paralyzed muscles requires local 
stimulation. Frictions with oil, vaseline, alcohol and water, 
tepid water, or hot water must be used several times a day. 
Where the surface circulation is still fair, cold water may be 
preferable. Passive movement must take the place of active 
exercise when the latter is impossible. The faradic current will 
stimulate and may improve whatever there is left of contrac- 
tility. Should it become totally inactive, the reversed galvanic 
current may take its place for the purpose of exercising the 



DISEASES OF THE NERVOUS SYSTEM. 339 

muscles. Otherwise the galvanic continuous current is emi- 
nently the nerve and blood-vessel stimulant, and must be used 
daily to keep up the circulation and thereby the nutrition of 
the degenerating tissues. It is best applied through large elec- 
trodes, and should be made to ascend and descend alternatively. 
Sessions of from six to ten minutes, one or two every day, are 
sufficient, but they must be continued a long time. I know 
that limbs which had remained unchanged in their atrophy 
and uselessness for years improved under patient galvanic 
handling, when persisted in for a long time. 

Mechanical appliances will prove useful. The arm must be 
so supported as to render the paralytic slipping out of the socket 
of the paralyzed humerus an impossibility. The rare cases of 
dorsal paralysis require a jacket or a properly fitting corset. 
The paralyzed (mostly extensor) muscles of the lower extremi- 
ties demand elastic bands, so as to counteract the contraction 
of the antagonistic flexors and thus to facilitate walking. Mean- 
while the remedial agents mentioned before must be continued. 
Strychnine will always do good, and phosphorus will act both 
as a nerve stimulant and as a tissue-builder. It may be given to 
a child a year old in doses of from half a milligramme (half a 
teaspoonful of the elixir of phosphorus of the United States 
Pharmacopoeia) to three-fourths of a milligramme daily. To 
expect an improvement of nutrition by ligating the paralyzed 
limb is a grave mistake. That procedure will tumefy, but not 
nourish, the constricted part. 

Consecutive club-foot requires the employment of proper 
orthopaedic apparatuses at as early a time as is judicious, to 
prevent an unnecessary degree of anaemia, atrophy, and loss of 
length. To avoid the necessity of such mechanical aids, an 
operation has been performed — arthrodesis — for the purpose 
of ankylosing the upper ankle-joint, in some cases also the talo- 
calcaneal joint. The after-treatment consists in the use of 
a plaster-of-Paris bandage, which should be carried three 
months by children under ten years, six weeks by adults. The 



340 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

highest degree of tendon contraction may require extirpation of 
the talus, but is usually overcome by tenotomies. After re- 
covery a snug shoe must be worn. 

Circumcision has been performed on children affected with 
poliomyelitis, without any justification either in theory or in 
practice. 

The varieties of hydrorrhachis (spina bifida) depend on the 
more or less extensive arrests of development and their second- 
ary changes. The treatment differs accordingly. In more ad- 
vanced years I have seen spina? bifida?, in the lumbar and in the 
cervical regions, whose connection with the spinal canal, origi- 
nally narrow, was totally obstructed, so that their removal 
caused no difficulty whatever. Cases accompanied by malfor- 
mations, contractures, or paralyses of the lower extremities do 
not respond favorably to treatment. Those rare ones which are 
complicated with superjacent tumors (mostly lipomata) or with 
hypertrichosis (very rare) must be carefully watched, for care- 
less operations on what was considered uncomplicated pseudo- 
plasms have proved fatal. Such as are of central origin, in 
which accordingly the posterior columns with the nerve-roots 
spread over the interior of the sac, give a grave prognosis. 
Spontaneous bursting of the sac must be guarded against, for 
much loss of cerebro-spinal liquor is apt to terminate fatally 
in a very short time. Puncture may be resorted to and re- 
peated, a fine needle being used. After each puncture pressure 
ought to be applied to prevent rapid filling up. A few cases — 
small ones of simple meningocele — have been known to get 
well in this way. Or, after the puncture, iodine may be in- 
jected. Morton's formula — iodine 1 part, potassic iodide 3 
parts, and glycerin 48 parts — has been very felicitous in his 
hands and in mine. Favorable cases have been successfully 
treated by the clamp, suturing, and gentle compression, and 
bad cases by extirpation of the sac and utilization of the peri- 
osteum of the patient. Robson transplanted that of a rabbit 
in 1883. 



DISEASES OF THE NERVOUS SYSTEM. . 341 

Nicolaier's discovery of the bacillus of tetanus in 1885, and 
its pure culture by Kitasato in 1889, together with the progress 
made in immunization and antitoxic treatment generally, add 
to our hopes of the curability of tetanus. Immunization against 
tetanus has been proved in mice, and recovery has taken place 
when serum was injected five hours after the introduction of 
the culture. But it is true that a hundred times the amount 
of serum was required in an animal infected only a quarter of 
an hour before, as compared with the amount required before 
infection was accomplished; it is also true that very few ab- 
solutely certain and indubitable successes have thus far been 
obtained, but there can be no reasonable doubt that most satis- 
factory results of antitoxic methods of treatment will be de- 
veloped shortly. The tetanus antitoxin prepared by the New 
York Health Department is recommended in rather large doses; 
three hundred cubic centimetres may have to be injected into 
a child of twelve years. "It is of vital importance that the anti- 
toxin be administered at the earliest possible moment, as the 
dose required to neutralize the tetanus toxin absorbed increases 
with great rapidity with each hour's delay," at the same time 
the disinfection of the locality of invasion by means of iodine 
should go on, "carbolic acid and bichloride of mercury are of 
little value for this purpose." Medicinal treatment should be 
kept up at the same time. The effect of heavy doses of the 
bromides, of chloral, of curare, and of opium is undoubted. 
Most of the cases of tetanus in the newly-born and in the adult 
that I have seen getting well did so under chloral, bromides, 
and occasional doses of opium. Carefully, but early, must the 
doses of chloral hydrate be increased. In some instances they 
were incredibly large. (See p. 116.) 

It seems certain that those cases of tetanus which are un- 
doubtedly of bacillary origin are least amenable to treatment. 
Such as are of rheumatic or traumatic origin, and even such 
as result from throat infections, are more easily influenced by 
remedies. 



342 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

6. Neuroses of Central or Local Origin. 

The treatment of eclampsia depends on its etiology. Ke- 
peated attacks may be the results of identical causes, — for in- 
stance, feverishness, intestinal disturbances, and emotions, — 
but they suggest the existence of epilepsy. Indeed, a single 
eclamptic attack cannot be distinguished from an isolated epi- 
leptic seizure. According to the various causes to which 
eclamptic convulsions may be due, the best preventives are 
regulation of the diet, of the bowels, and the removal of worms; 
the withholding of alcohol, coffee, tea, and improper foods; the 
watching of every kind of fever, from a simple catarrh to an in- 
flammatory or infectious disease. In households where there 
are babies known to be subject to eclampsia the clinical ther- 
mometer is indispensable. Catarrhal fever, intermittent fever, 
pneumonia, otitis, meningitis, and acute eruptive diseases are 
often ushered in by a convulsion. Tight bandaging, renal cal- 
culus, and splinters in the skin are to be suspected when no 
other cause is readily found. A normal dentition never pro- 
duces a convulsion, and "difficult dentition" as a cause of a 
convulsion is among the affections which are as rare as 
they are too readily diagnosticated.* The frequency of the 
habit of lancing the gums, to which many practitioners are still 
addicted, proves the frequent absence of diagnoses and the 
readiness with which tribute is paid to the prejudices of past 
centuries and to those of the female population. Cranial and 
encephalic rhachitis, with or without laryngismus stridulus, is 
often attended by convulsions, and requires antirhachitical 
treatment. 

The habit of regularly administering bromides to infants 
who have convulsions is a bad one. As a regular medication 
they ought to be reserved for epilepsy. The attack demands 
the removal of the cause. Irrigation of the stomach, or an 
emetic; irrigation of the bowels with water, soap and water, 

* See my "Dentition and its Derangements," New York, 1862. 



DISEASES OF THE NERVOUS SYSTEM. 343 

oil, turpentine, assafcetida; a purgative (calomel with or with- 
out an antifermentative, such as resorcin or salol, followed 
or not by castor oil); the proper use of a warm bath; a cold 
pack frequently repeated, with ice to the head and heat to the 
feet; the timely administration — in an urgent case antipyrin 
under the skin — of an antipyretic; chloral hydrate internally 
or by the rectum; inhalations of chloroform to shorten the at- 
tack, — all suggest themselves as most promising in certain 
cases. Chloroform ought not to be omitted, for any moment of 
a violent convulsion may occasion a cerebral hemorrhage with 
its dire results for life, or body, or mind. Sinapisms to the neck 
and to the extremities have often been recommended, but be- 
sides the possible after-effect of annoying and irritating the 
infant suffering from a vulnerable nervous system, they cannot 
be expected to have much, or sufficient derivative action. To 
quiet the irritability persisting after an attack, chloral hydrate 
with or without a bromide, or repeated small doses of codeine 
or extract of opium, or the camphorated tincture of opium 
may be administered. 

The causes of chorea minor — St. Vitus's dance — are either 
anatomical changes (some of them improvable, some incurable) 
or functional disturbances. Therefore the treatment should 
vary according to the etiology, but hardly a case will do well 
without attention to the functional treatment. Indeed, some 
forms of the latter are almost of a specific character. Preven- 
tion is indicated when the patient is of a neurotic constitution; 
the descendant of a neurotic family; when suffering from di- 
gestive or genito-urinary disorders (masturbation); when ac- 
customed to alcohol in more than medicinal doses, or when he 
has rheumatism or heart-disease. Capillary embolisms, cysts, 
tubercles, apoplexies, and exudative changes in the nerve- 
centres, particularly the brain, are not subject to preventive 
measures. The same holds good in any cerebral lesion located 
near the pyramidal tracts, — viz., in the cortex, the internal 
capsule, or in the basal ganglia. Demme observed a case 



344 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

depending on a fissure of the anus; it admitted of direct 
treatment; Soltmann a chorea of the left side after trau- 
matic depression of the right parietal bone; others report 
cases depending on shrinking cicatrices and on neuritis. 
I have observed a marked case of acute chorea which de- 
pended on spinal meningitis of the cervical portion. In this 
case ice, local depletion, purgatives, and ergot were the suc- 
cessful remedies. (Seguin's "Clinical Lectures," vol. i., 1872, 
second lecture.) In the American Journal of the Medical 
Sciences, April, 1886, and in the "Festschrift zum 70sten Ge- 
burtstag von Professor Henoch," Berlin, 1890, I published ob- 
servations of partly local, partly general chorea which depended 
on nasal reflexes due to catarrhal and inflammatory changes 
and to polypi. In all these cases the treatment and cure of dis- 
eases of the nose and naso-pharyngeal cavity are demanded pre- 
liminarily to the successful treatment of St. Vitus's dance. 

When heart-disease or a tendency to acute articular rheu- 
matism is the cause, preventives share largely in the success 
of the treatment. The hygiene must be strict and medicinal 
attention to the cardiac ailment close. The rheumatic child 
must be anxiously watched; pain, be it ever so slight, requires 
rest in bed for one or two days at least and tentative doses 
of salicylate of sodium. Helminthes must be expelled. 

Neurotic children should not be overworked, the school ses- 
sions must be short. Cool or cold washes, with friction, and 
systematic, but simple and brief, gymnastics in the open air, 
not in a close school-room, will strengthen them. The period 
of convalescence from any incidental disease must be passed in 
bed, which should be placed, if possible, near an open window. 
Anaemia must be carefully watched and treated. The patient 
should not be allowed intercourse with neurotic, or hysterical, 
or choreic, or epileptic, or even merely violent children; for 
some of the worst cases of chorea are those produced by fright. 
Headaches of a simply neuralgic or ocular origin must be at- 
tended to; the latter requires mostly glasses, sometimes the pro- 



DISEASES OF THE NERVOUS SYSTEM. 345 

tracted use of strychnine, but no misdirected and unauthorized 
operations when there is no disturbance of muscular accommo- 
dation; in the former aconitine will often prove helpful. 

A patient sick with chorea minor must be kept quiet in body 
and mind. Bad cases will not get well, unless confined to bed 
in a quiet room, with no visitors or excitements, with but a 
single person present to entertain or read to them, with a warm, 
protracted bath daily, and with ample sleep. Very bad cases 
must be kept sleeping eighteen out of twenty-four hours by 
means of mild opiates or chloral hydrate with or without 
bromides. Sometimes large doses are necessary, but the effect 
must be obtained. I have met with cases in which an occasional 
inhalation of chloroform was also required. Meanwhile, the 
symptomatic measures adapted to the average case should also 
be attended to. 

The best symptomatic remedy is arsenic, in the form of liquor 
arsenitis potassii or arsenatis sodii. Three doses are to be given 
daily, much diluted, after meals. When the eyes or the intes- 
tines begin to give trouble, or when a serious cutaneous erup- 
tion makes its appearance, or should the urine show albumin 
and casts, it is time to intermit. The doses must be increased 
slowly but persistently, according to the rule detailed on page 
131. The original dose can be doubled or quadrupled, indeed, 
can be increased almost indefinitely. The cause of failure on 
the part of arsenic is generally its insufficient dose. 

Of other remedies, nitrate of silver may be mentioned; it 
is of less service here than in some other ailments of the ner- 
vous system. Oxide of zinc or valerianate of zinc may be tried, 
if arsenic happen to be omitted. The galvanic current, warmly 
recommended by Benedict, has not satisfied me. Sulphur 
bathing, either natural or artificial, is adapted to cases conse- 
quent on rheumatism; it is indicated as after-treatment, as are 
also rational gymnastics and general roboration. 

Tetany has been observed in general disturbances of the gen- 
eral health, after gastro-intestinal disorders and during the 



346 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

presence of worms, in convalescence from acute and chronic 
(particularly infectious) diseases, after sudden exposures to 
changing temperatures, in chronic malaria, after injuries to the 
head, as the result of irritation, or as a consequence of the abuse 
of alcohol. The fact of the occurrence of tetany after total 
extirpation of the thyroid gland may lead in future to a correct 
diagnosis of many cases of tetany in children and to an accurate 
examination of the thyreoid gland. It is sometimes absent, or 
hypertrophied, or in an abnormal condition. The majority of 
cases are connected with rhachitis, mostly with its cranial (and 
encephalic) variety, and laryngismus stridulus. It is often 
found in cold springs, endemically, sometimes epidemically. 
The several causes enumerated above prove the occasional diffi- 
culty of a satisfactory etiological diagnosis, but suggest the pre- 
ventive and curative treatment. Pilocarpine has been mentioned 
as the successful remedy in a case which was probably caused 
by exposure. Gastro-intestinal disturbances (with or without 
autoinfection, accompanied by fever and by the occurrence of 
indican or aceton in the urine) demand proper medicinal and 
hygienic treatment. Tetany after infectious diseases and 
during convalescence generally requires rest in bed, good air, 
copious (perhaps forcible) alimentation, and roborants. A 
very mild galvanic current, prolonged warm (not hot) bathing, 
bromides, chloral at night, and small doses of codeine in older 
children will be required according to the severity of the cases; 
they will get well after weeks or months. A roborant and anti- 
rhachitical treatment with cod-liver oil, iron, strychnine in 
small doses, phosphorus, systematic exercise, and gentle hydro- 
therapeutic measures will restore the general health. The 
treatment with thyreoid gland has not proved a great success 
in the average case. 

Catalepsy is quite rare in children. I have seen but three 
well-marked cases, one of whom, a boy of thirteen, landed finally 
in a lunatic asylum. It is intimately related to hysteria and 
epilepsy, and often attended by psychical disorders. Both its 



DISEASES OF THE NERVOUS SYSTEM. 347 

prognosis and its treatment are dependent on the causes, 
among which fright, masturbation, chlorosis, malaria, helmin- 
thiasis, epilepsy, and melancholia have been enumerated. 
Thus, depletion, diaphoretics, emetics, nervines, anthelmintics, 
and electricity have been recommended. In most cases medi- 
cines are less effective than is attention to general hygiene, both 
physical and mental. In this respect it shares the fate and 
prognosis of hysteria, of which it may be considered one of 
the manifestations, the existence of which among children 
has been more extensively observed and studied since its pres- 
ence, particularly in connection with masturbation, was dis- 
cussed by me in 1875 (Amer. Journ. Obsi. and Dis. W. and 
Children). Hirschel and Fleisch observed catalepsy after inter- 
mittent fever, and Glas noted the case of a boy of five years, 
who had an attack of catalepsy (instead of a chill), followed by 
perspiration. In these cases quinine and arsenic take the place 
of other treatment, with better success. 

Another, though rare, symptom of hysteria is chorea magna, 
which differs from chorea minor in the occasional appearance of 
paroxysms of co-ordinate spasms with psychopathic prodromi 
and (frequently) termination. Altogether, hysteria occurs with 
all the symptoms met with in adults. It is not confined to the 
female sex in children any more than it is in adults, and ex- 
hibits the same debility and irritability of the nervous system 
in general and of emotions, reflexes, imaginations, and will in 
particular. Hyperesthesia (more frequent than anaesthesia), 
localized paralysis (muscles of deglutition, first branch of facial 
nerve, ptosis), paraplegia, strabismus, spinal and other neu- 
ralgias, tachycardia and palpitations are among the symptoms. 
The lack of mental and emotional equilibrium is an early 
feature. It is found in psychopathic families as the result of 
mental strain, in badly ventilated schools, and depending on 
undue ambition, masturbation, diseases of the ovary, and emo- 
tions. Hysteria in a child means, unfortunately, in most cases, 
hysteria for life. Still, training and education are capable of 



348 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

accomplishing a great deal in strengthening will and character 
and independence of thought. Such children are better off 
among strangers than at home. School sessions ought to be 
regular but short; work in the open air, housework, gym- 
nastics, and hydrotherapy, with general roborants, are indicated 
and prove successful. 

Athetosis, that peculiar form of localized (ends of upper ex- 
tremities mostly) spasm, can hardly be improved when congeni- 
tal. Now and then it accompanies polioencephalitis or cerebral 
tumors. Improvement is claimed to have followed the use of 
arsenic, bromides, and galvanism. 

Most cases of epilepsy are observed in, or date from, infancy 
and childhood. In no disease is hereditary influence more 
marked; the state of the future will have to see to it that 
epileptic persons are not placed in a condition to raise progeny 
equally cursed. Epileptic mothers must not nurse their babies. 
The child known to be epileptic must be trained very carefully, 
both physically and mentally. Alcohol and other stimulants, 
physical and mental exertions, and sudden emotions must be 
avoided. The hygiene of the skin and of the bowels requires 
particular care; the use of cold water is imperative; con- 
stipation must not be permitted. Feeding with gruesome 
nursery stories, tight dressing, and early schooling, also 
horseback exercise and swimming, are forbidden. In the in- 
terest both of the patient and of his schoolmates a public school 
should not be attended. The child ought to be instructed and 
trained with a view of preparing him for his future calling, 
which must not overstrain body or mind, must not be seden- 
tary, nor should it confine him, if avoidable, to the limits and 
influences of city life and air. 

No case of epilepsy should remain without treatment. It 
is true that there are spontaneous recoveries; even hereditary 
cases may get better or well; remissions are frequent; inter- 
vening acute diseases and many operations have frequently a 
favorable effect. On the other hand, Gerhardt saw a relapse 



DISEASES OF THE NERVOUS SYSTEM. 349 

after an intermission of twenty years. But the knowledge of 
these facts must not tempt us to procrastinate medicinal and 
hygienic interference, or to hold out a hope of recovery at the 
period of "second dentition/' of "puberty," or of "marriage." 

The best methods of treatment are always either specific or 
local. Symptomatic treatment may prove very successful with 
the aid of all-healing nature, but it is always a makeshift. The 
ideal indications for the cure of epilepsy ought to be — nay, 
must be — causal; its proximate seat is in the cerebral cortex, 
but its actual origin in anatomical lesions, mostly, of different 
localities. Thus, epilepsy may be cerebral, it may be the result 
of persistently abnormal circulation, or it may be of a reflex na- 
ture. A (brachial) Jacksonian epilepsy cured by the removal of 
a foreign body from the ear was reported by Monflier. Not a 
few cases have been traced to nasal irritation and relieved by 
nasal operations. All sorts of cerebral tumors, solid or cystic, 
the results of previous encephalitis and meningitis from inso- 
lation, otitis, or otherwise; arrests of cerebral development; 
premature ossification of one, some, or all of the cranial sutures 
and fontanelles; cerebral exhaustion from masturbation or pre- 
mature venery; diseases of the heart with secondary venous 
obstruction; congestion from other causes (in a case of Ger- 
hardt's, enlargement of the thyreoid); the influence of pro- 
longed use of alcohol or ergot; the sluggish brain circulation 
attending constipation and the general toxaemia of intestinal 
autoinfection; external irritations such as tumors, cicatrices, 
foreign bodies, and the reflex excitement produced by carious 
teeth, Schneiderian hypertrophy, and nasal and nasopharyn- 
geal growths; vesical and renal calculi; helminthes, from taenia 
to oxyuris; in older children delayed menstruation, are so 
many different causes of epilepsy. It is, therefore, only the 
most painstaking examination of all the organs and the whole 
surface of the body which gives a promise of finding the cause 
of the disease as well as the indications for rational causal treat- 
ment. 



350 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Arrests of cerebral development are not amenable to treat- 
ment; the method of dealing with the chronic results of cere- 
bral and meningeal inflammations, also the possible value of 
operations on prematurely ossified skulls, have been previously 
discussed. Most of the operations on the cranium undertaken 
for the purpose of healing epilepsy have not been successful, 
and the most enthusiastic promoters of such operations have 
rescinded their favorable opinions. Thus, the American Neu- 
rological Association, in a discussion which was mainly carried 
on by Sachs, Mills, Putnam, and P. C. Knapp, expressed itself 
very reservedly on this topic. But there is no doubt as to an 
occasional success, nor can there be any as to the feasibility of 
removing tumors from the surface of the cortex, or of open- 
ing and removing cysts and the results of new or old haemato- 
mata. B. Sachs and A. Gerster (Am. Journ Med. Sc, October, 
1896) came to the following conclusions: An operation is per- 
missible in traumatic epilepsjr when the case is not over one 
or two years old. When there is a depression of bone, the oper- 
ation is indicated at a later period, but should not be delayed. 
Trephining alone is sometimes sufficient. If the disease is of 
short duration, a part of the cortex may be excised. The com- 
plication with cerebral infantile paralysis, if the case be recent, 
is no contraindication to the operation. It must not be per- 
formed in epilepsy of long duration. Still, the human body, 
not being a machine manufactured wholesale on a uniform 
last, and medicine not being mathematics, the indications 
both for medical and surgical interference are neither geo- 
metrically exact nor are they gospel. For these reasons 
mistakes are always liable to occur. Jacksonian epilepsy will 
not always exhibit, at operations or at autopsies, the local 
lesions boldly diagnosticated. Aye, recoveries may not be ob- 
tained, though no error be committed; for, indeed, habitual 
convulsions may be so firmly established that even the removal 
of their original source is no longer an efficient cure. But the 
insufficiency of medicinal treatment may be such as to some- 



DISEASES OF THE NERVOUS SYSTEM. 351 

times necessitate or permit surgical interference as a possible 
last resort. 

It is particularly in cases produced by reflex from cicatrices 
and nasal irritation that local treatment, excision, cauteriza- 
tion, and the removal of polypi and adenoid growths have their 
signal, though rare, triumphs. The eyes have been accused — 
"eye-strain" — of producing epilepsy, and hence have been sub- 
mitted to operations. My remarks on that subject, as con- 
nected with chorea, I can but repeat here. As regards local 
treatment, we have also to consider the effect on the genital 
organs when they are the cause of epilepsy. There is no doubt 
as to the occasional efficacy of digitalis, lupulin, or camphor in 
such cases. In others a chemical effect is aimed at; thus, in 
epilepsy from chronic lead-poisoning, sulphur baths and sul- 
phur and iodide of potassium internally have exhibited good 
results. 

If the approach of an attack be perceived, the patient ought 
to lie down on a low couch; the inhalation of amyl nitrite, if 
in time, has warded off many seizures; its effect must not go 
beyond the first deep flush. If an aura rises from an extremity, 
a stout ligature around the limb may also act as a preventive. 
"When the seizure cannot be prevented, it must not be inter- 
fered with; no hands must be forcibly opened, no convulsive 
jerking meddled with; but the patient must be protected 
against biting his tongue or otherwise hurting himself. Among 
the drugs recommended for epilepsy every narcotic and anti- 
spasmodic has had its day. Valerian, pgeonia, and artemisia 
were once highly thought of; so was belladonna, and later 
atropine, with its paralyzing influence on blood-vessels. Curare 
was praised for its effect on the muscles. Sulphate of copper 
has been recommended. Nitrate of silver, in doses of not more 
than one or two centigrammes daily (gr. J-J), best in pills, 
may be continued, with intermissions, for a long time, and is 
credited with cures. It ought not, however, to be administered 
more than a month in succession, lest the skin show its effect. 



352 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Twice in my life have I thus succeeded in producing argyria. 
Zinc has proved serviceable: the oxide, the valerianate (25-50 
centigrammes daily), and the sulphate. The latter I have made 
much use of, beginning with three centigrammes (gr. -J) three 
times daily for an adult (a child in proportion), in increasing 
doses. Four grammes (1 drachm) are dissolved in one pint, 
of water, the first dose being a teaspoonful for an adult, ten or 
twenty drops for a child, the second the same dose plus one 
drop, the third the same dose plus two drops, and so on until 
after twenty days the double dose, after forty days the treble 
dose is reached. It takes a long time for tolerance to become 
exhausted; should this happen, a small reduction of the dose 
is all that is required. 

To reduce the irritability of the cortex and the general con- 
vulsibility, and thus in the course of time to cure epilepsy, the 
main reliance is on the bromides. I have not been able to con- 
vince myself of the injuriousness of the potassium salt. A 
belief in its harmful action has been the cause of the substitu- 
tion of the sodium, or a mixture of the potassium, sodium, and 
ammonium salts. Whichever plan is followed, there are certain 
rules which are paramount. The remedy must be given for 
years; it must not be interrupted unless there have been no 
seizures for years, except for very good reasons (excessive acne, 
paresis, sopor, headache, and perhaps the intervention of acute 
diseases). The doses must be sufficient; a child of two years 
may take three or four grammes (grs. 45-60) daily. It is best 
to give a large dose at bedtime, perhaps half of the daily 
amount; in this way the cerebral symptoms of overdosing are 
most readily avoided. When they appear the dose may be re- 
duced, but, except in rare instances, the remedy should not be 
stopped altogether. Perhaps the strontium or lithium salt may 
take its place for a time, but I cannot say that either has im- 
pressed me with the superiority which has been claimed for 
them. The addition of moderate doses of digitalis has often 
appeared to me to reduce the drowsiness brought on by pro- 



DISEASES OF THE NERVOUS SYSTEM. 353 

tracted large doses. Arsenic in small but regular doses will 
lessen the tendency to acne. 

I cannot say that bromides are badly tolerated in the even- 
ing; still, it is claimed that they have a disagreeable effect. In 
that case a sufficient dose of amylene hydrate to produce sleep 
should take their place. Weber, of Dahldorf, precedes his 
bromide treatment with a regular course of amylene hydrate; 
on the other hand, there are those who condemn its use alto- 
gether because of injurious effects which they claim to have 
observed (Jastrowitz, Jolly). 

Flechsig combines the bromide of sodium treatment with 
that of opium. His two or three daily doses of the latter, for 
adults, are from five to ten or twenty-five or thirty-five centi- 
grammes each (gr. f-6). Large doses cannot, however, be given 
except in well-supervised institutions. After six weeks it is 
suddenly discontinued and replaced by 7.5 grammes daily (2 
drachms) of the bromide. After this treatment has been con- 
tinued two months the daily dose is reduced to two grammes. 
Only when fright or other emotions were the proximate causes, 
the two remedies were combined early. Flechsig claims no 
direct effect, but only a preparatory action of the opiate. In- 
deed, during the opium treatment there was no relief; but in 
combination with bromide of sodium, cases which had lasted 
decades were improved. Eadcliffe, however (according to 
Gowers, Lancet, 1880, p. 552), found opium effective in some 
cases. Gowers saw but rarely any good effects from bromides 
and opium combined, but believes in the usefulness of small 
subcutaneous doses of morphine when attacks reappear often 
and violently. The latest journal reports on the Flechsig treat- 
ment are very contradictory. 

From Dr. Charles A. Dana I learned the use of urethan in 
epilepsy. I have seen it to stop epileptic convulsions (fifty 
every day, severe and mild) within a few days never to return 
for more than half a year until the child died from causes not 
connected with her epilepsy. The doses amounted to from two 



354 THEBAPEUTICS OF INFANCY AND CHILDHOOD. 

to three grammes (half a drachm to two scruples) a day, some- 
times refracted; sometimes a large dose was given at bedtime. 

Pasteur observed that in a patient under treatment for hy- 
drophobia the epileptic attacks ceased (as they do cease after 
operations of any kind, strong emotions, or acute diseases). For 
this reason Charcot suggested systematic injections of rabic 
virus for the purpose of relieving or curing epilepsy. Gibier 
has imitated the process and claims good results. Pierre 
Marie goes so far — a good deal too far — as to believe that "idio- 
pathic epilepsy," which he claims to be frequent, is of infec- 
tious origin in almost every case, is therefore preventable, and 
ought to be treated and cured with microbic toxin (Semaine 
Medicate, 1892, p. 283). 

The number of epileptics is so large, and the influence of 
the disease upon the intellectual, moral, and physical condition 
of the individual, as well as upon the state and mankind, so 
wide-spread, as to be alarming. The subject has finally roused 
the anxiety of philanthropists to a great extent. Country set- 
tlements of epileptics have been established in Europe, with 
beneficial results. As a result of combined efforts the following 
resolution was passed at a meeting of the American Neurologi- 
cal Association: 

"That it is the unanimous sense of the American Neuro- 
logical Association that the proper care of the epileptic class, 
so long delayed, be urged upon the public, upon State authori- 
ties, and especially upon all interested in the care of the sick 
and defective poor, whereby they may be retired from asylums 
and almshouses, and may receive the required care in such 
separate establishments as their deplorable situations demand.* 

One of the results of this resolution was an act of the Leg- 
islature of the State of New York, by which a tract of land in 
the interior of the State was set aside for the purpose of estab- 
lishing colonies for epileptics. The world is moving. 

Salaam spasm (spasmus nutans), a peculiar affection of the 
accessory nerve, must receive the treatment proper for its 



DISEASES OF THE NERVOUS SYSTEM. 355 

causes, which are either central (rhachitical) or reflex (from 
intestinal disorders). Many of the patients are thoroughly 
anaemic. There are indications for bromide of potassium, the 
positive pole of the galvanic current upon the convulsive mus- 
cle (sterno-cleido-mastoid (or) and trapezius), also massage and 
antirhachitical treatment. 

Stammering is pre-eminently a disease of the nervous system, 
and is probably caused by a diseased condition or insufficient 
tone of the cerebral cortex, with lack of equilibrium, exhibited 
in some by choleric temperament, in others by cowardice, to- 
gether with disturbance of will-power and an absence of co- 
ordination of respiration and the muscles of the larynx and 
mouth. In some it is the result of nervous talkativeness, fid- 
getiness, and flightiness on the part of parents or attendants; 
in some of imitation not checked at the proper time. Strength- 
ening of mind and body is the main indication. Training, cold 
water, and exercise will fortify the character; bromides may 
for a time relieve irritability. Co-ordination of innervation 
and muscle may be achieved by loud and slow speaking and by 
reading, reciting, and singing. Self-confidence must be encour- 
aged in every way. Among strangers and in institutions estab- 
lished for the purpose such patients are mostly benefited, not 
infrequently in a short time. Local affections of the respira- 
tory tract must be attended to, adenoid vegetations of the 
naso-pharynx removed, and other anomalies of the nares, pro- 
vided they interfere with respiration, corrected. 



VII. 

DISEASES OF THE DIGESTIVE ORGANS. 

A. The Mouth. 

1. Hare-Lip and Fissure of the Palate. 

The latter cannot be operated upon until the child is four or 
five years old. The former should undergo the operation, un- 
less there be a strong contraindication, on the first day of life, 
when the immediate necessity of feeding is not urgent. The 
difficulty of nursing is, in part, obviated by the successful 
closure of the cleft in the upper lip, and the sooner the de- 
formity is removed, the better are the chances for a correct 
position of the future teeth and for articulation. 

2. Tumors in the Oral Cavity. 
An adenoma of the parotid was noticed in a nursling by Eros. 
Fibroma occurs in the periosteum, enchondroma and osteoma in 
the lower jaw, sarcoma (epulis) in the alveolar process, where it 
mostly originates in the periosteum. They should be removed 
soon. The first (of the very few cases on record) congenital 
sarcoma of the tongue I reported in 1869 (Journ. Oost. and Dis. 
of W. and Child.). It was removed by the galvano-cautery. 
Biedert ("Lehrb. d. Kind.," 11th ed., 1894, p. 168) reports the 
case of a girl of ten years with sarcoma, which commenced in a 
tonsil and extended over all the neighboring organs. When she 
seemed to be almost moribund she was taken with erysipelas 
and got well. The report was made eight years after her re- 
covery, which took place with considerable cicatrization. The 
case holds out great hopes for Coley's treatment of sarcoma by 
means of the serum prepared from the streptococcus of ery- 
sipelas andHhe bacillus prodigiosus. 
356 



DISEASES OF THE DIGESTIVE ORGANS. 357 

3. Ranula. 

The sublingual glands are sometimes seen as gentle elevations, 
when the tongue is normally raised. Some acini of one or both 
glands, however, may undergo cystic degeneration and form 
cysts of any size up to that of a pigeon's egg. The same sort of 
cystic tumors are formed in the obstructed Rivinian duct and 
in the lymph-ducts between the genio-hyoid muscles, very rarely 
in the ductus lingualis or its ramifications. When they impede 
nursing, deglutition, or respiration, they should be removed. 
As the walls are very thin (mostly), enucleation is not practical; 
the simple incision is mostly useless because it will soon close 
up; the introduction of a silk-thread seton may favor suppura- 
tion and sepsis; the removal of a fairly large part of the visible 
wall, with subsequent application of the nitrate of silver stick 
(with immediate application of salt solution afterwards) gives 
the best results. 

Concretions in the efferent ducts of the sublingual and the 
submaxillary glands can mostly be expelled by gentle pressure. 
If not, a short incision will free them. 

4. Milia. Epithelial Pearls. 

Along and near the raphe of the palate of the newly-born 
and nursling there are (sometimes numerous) hard, yellowish- 
white conglomerates of small size. Now and then they rise 
above the level of the surface. They are mostly (not cystic, not 
comedones) accumulations of epithelia in the small vacuoles of 
the mucous membrane. Mostly they disappear spontaneously; 
sometimes, under the influence of injury and microbes, they 
ulcerate. Pus is occasionally seen. I have observed perfora- 
tions of the palate. In that condition they are sensitive or 
painful, and interfere with nursing and nutrition, and are the 
starting-points of thrush, or of still more serious infectious dis- 
eases. A daily application of a solution of nitrate of silver 
(1 : 50-500), mild when only the surface is ulcerating, and fre- 



358 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

quent brushing (not rubbing) with a solution of potassic chlo- 
rate or of sodic biborate (1 : 30-40) will be all that is required. 
The perforation alluded to is very exceptional. Syphilitic 
and diphtheritic (rare) perforations furnish their own indica- 
tions both for local and general treatment. 

5. Stomatitis. 

The catarrhal form, mostly with inflammation of the gums 
(gingivitis), results from uncleanliness (retention of food in the 
mouth), from constant sucking on fingers and nipples or is 
observed in connection with nasal catarrh, glossitis, pharyngitis, 
gastro-enteritis, peritonitis, or the exanthematic acute erup- 
tions. This mild form demands cleanliness, drinking of cool 
water (mainly after every feeding), cooler temperature of the 
food, unless it be breast-milk, and the washing either with 
chlorate of potassium or borax solutions. In those cases in 
which the mucous membranes and the tongue are dry, a solu- 
tion of nitrate of silver (1 : 500-1000) should be brushed on 
once a day. 

The follicular form, in which vesicles are found over the 
mucous membranes, tongue, and pharynx (not the gums), with 
a tendency to rupture, is very painful and often attended with 
high temperatures, and interferes with swallowing; it should be 
treated, besides locally, with chlorate of potassium, eight grains 
(0.5) in five ounces (150.0) of water and glycerin (10-15 : 1), a 
teaspoonful to be taken every half hour, and no water to be 
given immediately after so as to secure the local with the gen- 
eral effect. 

The ulcerous variety (stomacace) originates in the gums of 
the lower (more frequently than the upper) incisors and 
canines. The tissue undergoes a rapid parenchymatous dis- 
integration, looks white, is soft, breaks away, loosens the teeth, 
attacks the adjoining angle of the mouth and cheeks, which 
undergo the same destruction. There is copious salivation and 
offensive odor. As it is mainly observed after measles (most 



DISEASES OF THE DIGESTIVE ORGANS. 359 

frequently) or pneumonia, and infectious diseases generally, 
feeding (which is often resisted), tonics, and stimulants are 
urgently indicated. Internally, chlorate of potassium as in 
the follicular form, in doses not larger, but more frequent. 
Most cases do not require anything besides, with the exception, 
perhaps, of the local application, a few times a day, of perman- 
ganate of potassium solutions (1 : 250-500). 

The aphthous variety, with yellowish or gray spherical and 
flat fibrinous deposits between epithelia and the tissue of the 
mucous membrane, sometimes complicated with small hemor- 
rhages, may become dangerous when grave, and may interfere 
with swallowing. When there is a tendency to superficial ulcer- 
ation, nitrate of silver in water (1 : 50) may be gently applied 
once daily. Other treatment was outlined above. 

6. "Bednafs Aphthae." 

They are not aphthae, but flat and more or less extensive 
ulcerations, resulting from atrophy of and injury to the epi- 
thelium and mucous membrane of the alveolar processes and 
the palate of the very young (first month). In the newly-born 
desquamation takes place over all the integuments, both skin 
and mucous membranes. Thus, normally, the epithelium is 
thrown off. The oral mucous membrane is very thin, over the 
posterior alveolar process it is very tense, and mostly so about 
the insertion of the pterygo-mandibular ligament. There, 
while the mouth of the newly-born is kept opened, the mucous 
membrane becomes quite pale. Thus a slight stomatitis, a 
moderate ill nutrition, and careless and rough handling of the 
mouth of the baby, cause abrasions and ulcerations, which may 
be quite small, or extend over square inches. They are danger- 
ous to the same degree as they interfere with nursing or feed- 
ing, and facilitate the invasion of microbes which are numer- 
ous, but accidental. Still they may cause an infectious disease. 
Thrush is a frequent sequela. The above etiological remarks 
preach the sermon of prevention. Look after your nurses, their 



360 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

finger-nails, and the material they shove into the babies' 
mouths. Nitrate of silver (1 : 50-500) in one daily application, 
and gentle brushing with boracic acid (1 : 30-50), or with bi- 
borate of sodium, will mostly suffice. If a stronger disinfectant 
be required, permanganate of potassium (1 : 200-500) is pref- 
erable. Much crying on the part of the baby is injurious by 
the stretching of mucous membrane of the posterior lower 
alveolar processes. After each meal a few teaspoonfuls of water 
should be given to clear the mouth of food remnants. 

7. Thrush. 
Membranous stomatitis is very frequent and popularly known 
as thrush (muguet). The postnatal desquamation of the epi- 
thelium, the open mouth which allows the constant passage of 
air and microbes, the narrow nares which add to that predis- 
position, uncleanliness, retention of food in the mouth, excess 
of sugar in the food, previous pneumonia or infectious disease, 
which add to the hyperemia of the oral cavity, facilitate the 
deposit of oidium (no healthy epithelium permits it), which, 
with streptococci and staphylococci, detritus, a little fibrin, and 
foreign remnants, form granulations and membranes mainly 
on surfaces covered with pavement epithelium (mouth, tonsils). 
Oidium is also found in the intertrigo of the nates, occasionally 
even in the cranial cavity; its gonidia are met with in the gas- 
tro-intestinal tract, where they cause gastritis and enteritis, 
atrophy, and possibly death. It is therefore necessary to treat 
thrush early. The membranes can almost always be scraped off 
easily. A solution of boric acid (three or four per cent.), of 
biborate of sodium (two or three per cent.), or of permanganate 
of potassium (one-half to one per cent.) should be applied five 
or six times daily. A daily application of nitrate of silver 
(1 : 500) is useful when the membranes have been removed. 
Internally, as gastro-intestinal complications are frequent, re- 
sorcin and bismuth may be administered (bism. subnitr. one 
gramme = grs. 15, resorcin twenty-five to forty centigrammes 



DISEASES OF THE DIGESTIVE ORGANS. 361 

= grs. 4-6, water fifty grammes, glycerin ten, a teaspoonful 
every two hours). 

8. Infectious Stomatitis. 
Hemorrhagic stomatitis is observed in scurvy, in diphtheria, 
and other infectious diseases; the diphtheritic form in diph- 
theria, the syphilitic, with its circumscribed whitish or grayish 
condylomata and other symptoms in nose, larynx, skin, or 
bones, in syphilis. The treatment of these local manifestations 
was discussed in other chapters. Mercurial stomatitis is rarely 
seen in infants and children, the less the younger they are. 
When it does occur, chlorate of potassium internally, and as 
a mouth-wash (1 : 30), is as good a curative as it is a preventive. 

9. Noma. 
Phlegmonous gangrene of the cheek, sometimes originating 
in the gums, is commonly known as noma. It is of unknown 
cause (neuropathic, microbic, thrombotic ?), is mostly observed 
after measles, typhoid fever, scarlatina, or other infectious dis- 
eases, or after reckless mercurialization. The hard, black node 
grows fast, the fearfully fetid ulceration destroys soft parts, 
teeth, bones, and finally life, unless the process be stopped. The 
actual cautery (electro-, thermo-cautery) employed once or 
more is most effective, also fuming nitric or sulphuric acid; 
when it has stopped, the permanganate of potassium (1 : 100) 
may be applied, also tincture of iodine or formalin (1 : 15-30). 
The strongest stimulants in large doses, alcoholic beverages, 
musk, and strychnine should be given. As it is only seen after 
infectious diseases, etc., we should learn the lesson of not rely- 
ing too much on the lazy nihilism of thoughtless "expectant" 
methods. 

10. Sublingual Adenitis. 

The inflammation of the sublingual gland (sometimes con- 
nected with parotitis) is mostly seen in the puerperal infections 
of the newly-born. It may heal, but requires early incision to 
relieve the pus, and frequent disinfection with permanganate 



362 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

of potassium (1 : 200-500). The abscess may become very 
large if the surrounding cellular tissue participates in the sup- 
puration. The incision should be large, and disinfection very 
careful. 

11. Parotitis. 

The endemic and epidemic variety was treated of on page 
245. If the Stenonian duct be obstructed by simple or mer- 
curial or ulcerous stomatitis, or by diphtheritic deposits, the 
gland will swell and get inflamed. Cold applications, gentle 
massage with green soap, or with an iodide of potassium lanolin 
ointment, will succeed, unless there be suppuration. In this 
case an incision is required. A metastatic form of parotitis, 
with numerous cocci in the pus, may be observed in variola, 
typhoid fever, scarlatina, and anaemia. Warm fomentations, 
large incision, and thorough disinfection are demanded. 

12. Difficult Dentition. 
Dentition is a physiological process; before a tooth protrudes 
the gums above it are slowly absorbed so as to show a slight 
depression, with no hyperemia. Some time previously the 
gums are raised and more or less hyperaemic. The only per- 
ceptible symptom is the eagerness of the baby to bite. In- 
creased salivation has nothing to do with dentition, but with 
the increased function of the salivary glands, which itself, like 
the growth of the teeth, of the head, and of the brain, is the 
result of the physiological hyperemia of that part of the body. 
When the gums are abnormal, hard, tense, perhaps under the 
influence of a stomatitis, there may be a slight fever, hot head, 
sleeplessness which is improved by taking the baby up (head 
elevated), even some muscular twitching; for at that time ex- 
citability is great and inhibition insufficient. One or two deci- 
grammes of a bromide may be given (grs. 1 J-3) once or often, 
and the mouth should be washed with cool water. The period 
of dentition is also the time of many disorders and diseases, 
which are not easily diagnosticated and tempt the practitioner 



DISEASES OF THE DIGESTIVE ORGANS. 363 

to suggest or accept the diagnosis of difficult teething. Lancing 
the gums, which, with calomel, was the every-day treatment of 
infants at the time of teething, has lost most of its charms. 
There are practitioners who prefer making a diagnosis of the 
real condition of the ailing baby, and that is the main treat- 
ment I recommend for "difficult dentition." 

13. Dental Ulceration. Riga's Disease. 
When there are but two lower incisors, and they the only teeth 
present, the tongue is irritated by contact and friction; that is, 
as is readily understood, particularly frequent in whooping- 
cough. In this way the dental ulceration is caused. When the 
irritation lasts long, and results in a secondary inflammation 
with hyperplasia of the tissue, the tongue adjoining the 
frenulum is not only discolored, grayish, and slightly granu- 
lating, but exhibits a slight excrescence, with a somewhat ir- 
regular surface, and of marked density. That is what is called 
Riga's disease (by Fede and Concetti, who say it is very 
rare in Rome, but very common in some parts of Southern 
Italy). The name is an unnecessary addition to our nomencla- 
ture. According to the condition of the surface it may be 
moistened frequently with a solution of chlorate of potassium, 
or of borax, or of permanganate of potassium, or.be cauterized 
with the solid stick of nitrate of silver once every two days. 
The ulceration or tumor is almost certain to disappear when 
a few more teeth make their appearance in the lower jaw. 

B. The Tongue. 
1. Congenital Anomalies. 
They are more or less amenable to surgical relief. The bifid 
tongue (arrest of development, consisting in the non-juncture 
of the two halves of the first branchial arch) may thus be im- 
proved. A sarcoma I removed with the galvano-cautery (see 
p. 356). Lipoma is mostly located on the tip of the tongue, is 
quite small, or reaches the size of a hen's egg; is sometimes 



364 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

pedunculated, and annoys nursing and nutrition. It should be 
extirpated, as also dermoids and cystic hygromata. The latter 
may also be injected with an irritant fluid (Lugol's solution, 
alcohol), lymphangioma may be punctured with the actual cau- 
tery in different places. The latter is one of the forms of macro- 
glossia; its other variety is muscular; it is mainly this latter 
which enlarges the tongue in every direction, makes it protrude, 
and excoriate, and dislodge the teeth. It has been reduced by 
the ecraseur and by ignipuncture. A wedge-shaped piece may 
be excised and the flaps joined. Hypertrophy of the tongue 
accompanying any of the varieties of cretinism requires the 
prolonged use of thyreoid. Adhesion of the tongue (ankylo- 
glosson), when in the rare form of extensive epithelial cohesion, 
is easily relieved by gentle traction, or separated by means of a 
blunt probe; when caused by the shortness and extensive inser- 
tion of the fraenum in the floor of the mouth, it requires an in- 
cision by scissors. It is better to make a superficial incision 
than to cause a hemorrhage which is stopped with difficulty. 
The affection does not interfere with nursing, so the little oper- 
ation is not urgent. 

2. Glossitis. 

Superficial changes of the tongue (erythema, catarrh) partici- 
pate frequently in the same alterations of stomatitis, pharyn- 
gitis, infectious diseases, and digestive disorders. The latter 
do not influence the tongue, however, so much as they do in 
adults. These superficial alterations require no treatment. 
Very little, if any, is required in the peculiar changes of the epi- 
'thelium, which is thrown off in the shape of smaller or larger 
islands and accumulated so as to form whitish and elevated 
edges round the bare spots ( (C pityriasis lingua"). It is only 
bad cases that require treatment. Lactic acid in solution has 
been recommended. I prefer nitrate of silver, once daily 
(1 : 500). The same solution I recommend on the smooth red 
tongue with or without fissures; it is mainly the latter which 
should be touched by the medicine. A mouth-wash of chlorate 



DISEASES OF THE DIGESTIVE ORGANS. 365 

of potassium and the internal administration of the same is 
beneficial in all of these conditions, alone or in combination 
with the above; also in most ulcerations, those caused by 
carious teeth or in the attacks of epilepsy. The acute inflam- 
mation of the tongue (acute glossitis), however, should not wait 
for the slow effect of any treatment. Its rapid swelling and 
intense redness, with its tendency to suppuration, demands a 
deep and long incision, more than a mere scarification of the 
surface. 

C. The Thkoat. 

1. Pharyngitis, including Amygdalitis ("Tonsillitis"). 

It is met with in many varieties, catarrhal, phlegmonous, 
erysipelatous, lacunar, follicular, and parenchymatous. All the 
diseases of the mouth may descend into the pharynx. The 
catarrhal inflammation of the pharynx is, however, apt to be 
more serious; fever, dysphagia, even convulsions are noticed, 
besides annoying or dangerous complications with nasal dis- 
eases. Exposure, dry (furnace) air, exertion (screaming) may 
bring it on. Nasal irrigations relieve the naso-pharynx and 
the pharynx of accumulations of mucus. Gargles are not so re- 
liable (see p. 83) as applications of ice-cloths, or of ice-bags, 
chlorate of potassium as advised above, with small doses of 
tincture of belladonna, also an astringent spray for older chil- 
dren. Tonsils, when swollen, are relieved by a scarification 
made at an early period. In that way chronicity may be 
avoided, with its liability to admit microbic infection and to 
cause the development of adenoid vegetations. The lacunae 
(crypts) of the tonsils, as they do not recede at all into their 
tissue, but are mere surface depressions, are the seat of a super- 
ficial process partly parasitic and partly irritative. The de- 
posits, sometimes large enough to form membranes, are made 
up of epithelium, detritus, and cocci, or, instead of the latter, 
leptothrix. This latter form was first described by B. Fraenkel 
in 1873. Loose deposits may be scraped off, and the sore sur- 



366 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

face (in docile children) touched with concentrated carbolic 
acid, or nitrate of silver either solid or in strong solution. 
Chlorate of potassium in frequent small doses internally. 

Follicular amygdalitis, the process being in the depths of the 
follicles, is liable to cause more general symptoms. High fever, 
pain, headache, even convulsions are very common. Epithelia, 
detritus, and a great variety of microbes form the tufts rising 
out of the follicles and the membranes in which a number of 
tufts coalesce. It will be discussed again together with diph- 
theria. 

Parenchymatous inflammation of the tonsils shares the char- 
acter and symptoms of phlegmonous pharyngitis in general, 
sometimes to an unusual degree. It results from or follows the 
(catarrhal or) follicular variety. Being caused by the latter it 
is originally localized, the abscess originating in a single fol- 
licle. That is why it is mostly on one side only, but may occur 
once or twice a year, until all the follicles are destroyed by sup- 
puration. An early incision should be made and followed by 
disinfectant gargles or medicines (chlorate of potassium). 

The abscesses of phlegmonous pharyngitis may be found any- 
where, without a trace, perhaps, of a microbic cause. Some are 
found in the submucous tissue, some hidden away behind a 
tonsil. They require an early incision. Erysipelas of the 
pharynx has no tendency to suppuration, but to considerable 
swelling, which may be so intense as to require tracheotomy. 
If intubation be possible, it should be preferred. Ice-applica- 
tions; ice-pills. Baginsky recommends a five-per-cent. ichthyol 
vaseline ointment. 

The chronic form of parenchymatous amygdalitis is some- 
times congenital (often hereditary), otherwise the result of re- 
peated acute processes. Scrofula predisposes. Mouth-breathing, 
vertigo, nocturnal (morning) cough, dyspnoea, incontinence of 
urine, night-terrors, ear-affections, mental hebetude, rheumatic 
affections, insufficient development of the chest, are symptoms 
or consequences. The chronically enlarged mass cannot be in- 



DISEASES OF THE DIGESTIVE ORGANS. 367 

fluenced by medication, or astringent applications. It is use- 
less to tamper with caustics of any kind. Eesection is the only 
quick relief, to be followed, mainly during epidemics of diph- 
theria, by disinfectant washes or medicines. If the anterior 
arch of the soft palate is adhering to the tonsils, it must be 
loosened first to avoid hemorrhage. If this occur the readiest 
means to suppress it is digital compression inside. If the oper- 
ation be objected to, the galvano-cautery (after anaesthesia by 
cocaine) may take its place. 

Follicles which remain open, and permit a probe to enter a 
centimetre and more, are the causes of constant annoyances, 
new deposits, microbic invasions, etc. They ought to be burned 
out with the electro-cautery or ripped open with a rectangular 
hook suggested by Moritz Schmidt, and improved by Gleits- 
mann, who sharpens one of the edges. 

2. Retro- and Latero-Pharyngeal Abscess. 
The lymph-nodes of the posterior wall of the pharynx drain 
the tonsils; the deep facial glands the orbit, jaw, and pharynx; 
the superior deep cervical glands the cranium, larynx, thyreoid, 
and pharynx. The intense growth and hyperemia of all the 
parts concerned during the first year of life, the frequency of 
stomatitis, pharyngitis, and rhinitis, and the activity of the 
lymph system at that period explain the frequency of retro- 
pharyngeal abscess in the second half of the first year. After 
the completion of the second year it is rare. Cases depending 
on genuine caseous tuberculosis of lymph-nodes are very rare, 
those resulting from caries of a vertebra not frequent. After 
all, Koplik (N. Y. Med. Journ., April 4, 1896) justly declines 
to accept the existence and name of idiopathic abscess; indeed, 
nothing should be called idiopathic, the cause of which is 
primarily located in another organ, or at a distance, though 
in the same class of tissue. The worst cases are those devel- 
oped through scarlatinous pharyngitis, or during erysipelas 
(rare) or measles; they have a tendency to become gangrenous 



368 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

and descend into the mediastinum, or to be, on the basis of 
uniform infection, complicated with pneumonia or suppurative 
pleurisy. The diagnosis is secured by dyspnceic, interrupted, 
snoring respiration, stiff neck (often held sideways), difficult 
deglutition, tinny voice, which will not be forgotten if heard 
once, frequently by the occurrence of a lateral swelling which 
can be seen outside, and by the presence of a posterior or lateral 
swelling, which can more often be felt than seen. The symp- 
toms are mostly urgent, sudden deaths not uncommon, and the 
abscess should be opened when felt, or even indistinctly felt to 
fluctuate. No anaesthesia. Hard swellings (in rare cases syphi- 
litic) should not be incised. The finger should never be used, 
or permitted, to burst an abscess though ever so soft; for the 
pharyngeal space being narrow (the larynx, as shown by Sym- 
ington, is higher by one vertebra in a child than in the adult), 
pus, which is quite copious mostly, may be forced into the 
larynx. The abscess may be opened in most cases by a hard 
silver probe, or director, which is run in quickly and made to 
tear a long opening, in others with a bistoury covered to nearly 
its point with adhesive plaster, or, better, with a covered knife 
which is withdrawn at once and the sheath of which is used to 
enlarge the opening. Immediately after the incision the head 
of the patient should be thrown forward, and gentle pressure 
employed laterally. There is rarely any hemorrhage; if there 
be, ice may be forced into the mouth; or ice-water injected 
into it forcibly, a single moment, will contract by reflex the 
small bleeding vessels. A sponge with a solution of antipyrin 
(ten to forty per cent.) will seldom be required. If the opening 
is large enough, a second incision will not often be necessary. 
In all cases where the lateral swelling is large and fluctu- 
ating or where the abscess is due to vertebral disease, or 
to scarlatinous or other sepsis, it is best to incise laterally be- 
hind the sterno-cleido-mastoid muscle, and to disinfect and 
drain. This method should not be followed except in the cases 
indicated, or when the mouth cannot be opened (contraction of 



DISEASES OF THE DIGESTIVE ORGANS. 369 

the masseters), or when the presence of the abscess is diag- 
nosticated, but its location such as not to be reached by an in- 
cision from inside. The after-treatment is like that of phleg- 
monous pharyngitis generally. 

The diagnosis from a hematoma or from an angiomatous 
tumor, both of which are rare but will occur, should not be 
missed; for a mistaken diagnosis may cause death. Dangerous 
hemorrhages may take place from a branch of the pharyngeal 
artery when the anterior palate is injured in a resection of the 
tonsil, or from a branch of the external maxillary artery when 
a peritonsillar or latero-pharyngeal abscess is incised far away 
to the right or to the left. Septic abscesses may also lead to 
the spontaneous perforation of a large artery. Four hemor- 
rhages took place within six days, the last of which proved 
fatal, in a case of latero-pharyngeal abscess which resulted from 
what appeared to be a mild case of a streptococcus pharyngitis. 
The autopsy revealed a large opening in the right internal 
carotid which should have been ligated to save the child. 

3. Adenoid Vegetations. 
They were first described by W. Meyer, of Copenhagen, in 
1870, and their influence on articulation, hearing, and intel- 
lectual development and on countenance recorded. They are 
lymphoid swellings in great numbers, sometimes covering the 
whole pharyngeal roof, sometimes accumulated in one large 
mass (Luschka's "pharyngeal tonsil"), or in two masses with a 
recess between them. They cause or are dependent on or con- 
nected with catarrh of the nose and the pharynx, give rise to 
occasional bleeding, headache, cerebral congestion, cough, 
laryngitis, otitis, sometimes facial erysipelas, retard intellectual 
development, and produce the expression of stupidity common 
to all mouth-breathers. As the normal nose and naso-pharynx 
are full of microbes, the adenoid vegetations have been studied 
in reference to them. Streptococci, staphylococci, and pneu- 
mococci have been found on them, also leptothrix. Dieulafoy 

24 



370 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

found tubercle bacilli in very many, and was disposed to claim 
the vegetations as tubercular, Gouce, however, not once in two 
hundred and thirteen cases, in thirty of which tuberculosis 
could be found in other organs. Dieulafoy's assumption is one 
of the many instances of the dangers, not of close investigation, 
but of previous conclusions based upon the mere presence of 
actual or alleged characteristic microbes. Contraction of the 
nose, pointed arching of the palate, and dental deviations with 
shortened and low inferior maxilla are not the results of ade- 
noid vegetations, but of original rhachitis or other (congenital) 
anomalies. Nasal irrigations of salt-water, boracic acid solu- 
tions, etc., while relieving the obstruction and catarrh of the 
naso-pharynx, are capable of reducing congestion and some- 
times render an operation superfluous. The latter, however, is 
preferable in almost every instance. As the vegetations spread 
often over a large surface, instruments like Gottstein's, which 
remove the prominences from a large area, are best. Del- 
stauche's modification of that instrument to which are added 
two sharp hooks bent downward, is a good one and applicable 
to larger tumors which can be caught. The small ones should 
be rubbed off with Gottstein's. The instrument should not be 
carried sideways in order not to injure the cartilaginous edge 
of the Eustachian tube. During or immediately after the oper- 
ation the head should hang down to avoid bleeding into the 
air-passages. Bleeding will stop spontaneously, or by a brief 
compression with the finger, or an application of a sponge 
dipped in ice-water. If there be more, the pressing on of a 
sponge dipped in a twenty- or forty-per-cent. solution of anti- 
pyrin in water is advisable. 

4. Fistula Colli Congenita. 
It is caused by the incompleteness of the closure of the 
second branchial arch. It begins near the sterno-cleido-mus- 
cle and terminates in the pharynx. Here it is either open (com- 
plete fistula) or not (incomplete). If open inside, and closed in 



DISEASES OF THE DIGESTIVE ORGANS. 371 

the middle, it forms a diverticle. Injections of iodine have 
been made to close it, and good results have been claimed. The 
total extirpation is by far preferable. 

D. The (Esophagus. 

Diseases of the mouth and pharynx descend into the oesopha- 
gus: catarrh, thrush, diphtheria. Injury by carbolic acid re- 
quires oil, also sulphate of sodium in solution; by acids: chalk, 
sodium bicarbonate, soap; by lye: fruit-juice, vinegar; by hot 
water: ice or ice-water, and cold applications. The sympto- 
matic treatment requires opiates. 

Stricture may be congenital (Demme). It follows injuries 
(mechanical or chemical) after months or sometimes years. 
Above the stricture a diverticle is apt to form, with the usual 
symptoms. Dilatation should be very gentle and gradual to 
avoid perforation; no metal instruments should be used. Gas- 
trostomy is performed to facilitate both nutrition and dilata- 
tion from below. Hjort claims to have opened a stricture in a 
boy of fourteen years by electrolysis in two sessions, the nega- 
tive pole of from ten to fifteen elements being introduced. 

Foreign bodies should be extracted, if possible, according to 
the methods taught for adults. If that be impossible, because 
of size or shape, they should be forced down into the stomach. 
If that fails, cesophagotomy is indicated. Of the one hundred 
and twenty cases of cesophagotomy collected by Fischer, four 
were under two years, eleven from two to ten, four from ten 
to fifteen years, altogether with a mortality of thirty-three per 
cent., due more to delay, and consequent sepsis, than to the 
operation. Gerster saved a boy of two years, in spite of deep 
ulceration caused by the foreign body, and a girl of nine years; 
Alexandroff, a boy of two years and nine months.* 

Periesophageal abscess may result from descending retro- or 
latero-pharyngeal abscess. Diseases of the vertebra? (the 

* F. KareTrski, Die ChiriTrg. Krankh. d. Kind., 1894, p. 367. 



372 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

oesophagus being in close contact with the cervical portion of 
the spine), of glands, pleura, and pericardium, also as foreign 
bodies will cause it. Glands may be found tumefied, the larynx 
dislodged, a soft swelling may be felt in the fauces. If it be 
within reach, an early incision should be made. 

E. The Stomach. 
1. General Nosology. Dyspepsia. 
The indications for the therapeutics of the stomach, both 
dietetic and medicinal, are by no means simple and clear in 
every individual case. For it is difficult to make an exact 
diagnosis of the anatomical condition of the surface and the 
tissue of the organ, because of the frequent combination of 
various conditions. Indeed, the boundary-line between a sim- 
ple functional dyspepsia and a gastric catarrh is perhaps never 
made out clearly. The epithelium of the mucous membrane 
does not belong to it exclusively, but spreads in the contiguity 
of the tissue into the muciparous and the peptic glands. Thus 
the inflammatory condition of the surface becomes at once a 
"parenchymatous" affection, though it be possible that an 
uncomplicated catarrh and an uncomplicated inflammation 
have an occasional existence. This, however, will last but a 
short time, and unless a gastric catarrh, or a dyspepsia, or an 
intestinal irritation — for the intestine shares the peculiar ana- 
tomical condition of the epithelium of the stomach — be re- 
lieved at once, the merely functional or superficial disorder be- 
comes organic and deep-seated. These changes may refer either 
to the tissue or to the secretion. Inflammatory thickening, ero- 
sions, ulcerations, or (Moncorvo) dilatation of the stomach will 
be observed in a great many instances. The secretions become 
abnormal. The normal hydrochloric acid of the gastric juice 
is almost invariably diminished; now and then a case will be 
found, but in older children only, in which it will be increased 
in quantity; still, as a rule, it is wanting or but scantily sup- 
plied. Lactic acid, however, is produced in much larger quan- 



DISEASES OF THE DIGESTIVE ORGANS. 373 

tities than the first stage of normal digestion requires, and with 
it acetic, butyric, and the rest of the fat acids. With this 
variety of changes the indications for treatment go hand-in- 
hand; others are suggested by the multitude of etiological 
factors. The direct paralyzing influence of heat, the imme- 
diate effect of irritant and bulky ingesta, and the poisonous 
action of bacteria introduced in food and rapidly multiply- 
ing render the intelligent and effective treatment of many of 
the cases which occur in the practice of every medical man a 
matter of great difficulty and responsibility. Nothing is more 
common, but less appropriate, than routine treatment directed 
against a variety of cases. 

The importance of diet in all questions connected with the 
pathology of the digestive organs justifies the repetition, in 
this place, of a few main points, the elaboration of which may 
be found in the first chapter of this book. 

The principal cause of the diseased conditions of the diges- 
tive organs of the young is to be sought for in improper food. 
Not even mother's milk will always agree with the baby; cow's 
milk cannot possibly take its place as a legitimate and satis- 
factory substitute. Much less reliance can be placed on manu- 
factured or home-made mixtures of unequal composition and 
doubtful quality. Children of more advanced years resemble 
adults in this, that they are endowed with more resistance to 
damaging influences. But the infant and young child are in 
constant danger of losing their pl^siological equilibrium by 
slight changes in feeding or by the deterioration of foods. The 
readiness with which milk, which is indispensable as a food, 
will decompose, acidulate, and become indigestible, renders the 
greatest attention a necessity in the interest of prevention. 
That attention must be first directed to the differences between 
cow's and woman's milk, which ought to be obviated as much 
as possible. The former contains more casein, usually less fat, 
less sugar and chloride of sodium. Besides, the casein of cow's 
and woman's milk differ both chemically and physiologically. 



374 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

That has always been so, and will be so, though a recent journal 
article declares the fact — or its assertion — a "bugbear." The 
former is less digestible, and its amount in the food given an in- 
fant must not be larger than one per cent., rather smaller. On 
the other hand, a large percentage (9-12) of fat is contained in 
every normal defecation of an infant fed on breast-milk, thus 
care should be taken not to exceed the quantity of fat contained 
in this normal food when artificial feeding is resorted to. In- 
deed, to what extent fat administered in excess, and indiscrim- 
inately, is apt to produce diarrhoea, is best illustrated by the 
"fat diarrhoea" which has been a frequent topic for discussion 
in medical journals. Water, salt, and sugar must be furnished 
the infant in sufficient quantities. 

Water is often wanting in infants' and children's food, and its 
absence is the cause of dyspepsia and of anatomical changes in 
the digestive organs. Its role in the organism is very manifold. 
Besides its influence on general metamorphosis, it is required 
to assist in pepsin digestion. In artificial digestion, albumin is 
liable to remain unchanged until large quantities of acidulated 
water have been supplied. The very presence of peptones even 
in the stomach requires water to facilitate their solution and 
absorption. The immediate relief felt by a draught of water 
taken during the prsecordial heaviness and discomfort experi- 
enced after a hearty meal is a matter of daily experience. In- 
fants and children — mainly the former — receive too little 
water. Whenever they are thirsty, both in winter and in sum- 
mer, they are given milk, — that is, food; and many a case of 
dyspepsia, with its results, could be obviated by adding plenty 
of waiter to the food. Excess of water, if under ordinary cir- 
cumstances there is such a thing, is attended with less incon- 
venience or danger, for it is readily absorbed and eliminated. 

Chloride of sodium ought to be added to most foods of infants 
and children. For instance, vegetable diet contains more potas- 
sium and less sodium than all the varieties of milk, and milk of 
herbivores more potassium than that of carnivores. Thus, cat's 



DISEASES OF THE DIGESTIVE ORGANS. 375 

milk contains sodium 1 to potassium 0.76, woman's milk 1 : 1, 
13-4.4, and sheep's and cow's milk 1 : 5.6. The amount of 
salt contained in woman's milk depends greatly on the presence 
of salt in her food. Thus many a defective milk can be reme- 
died by the mother or wet-nurse by adding salt to her food. 
Particularly is that necessary in dyspepsia and gastric catarrh 
in the baby, one of the main symptoms of which is the presence 
of large and hard curds in the masses brought up by vomiting 
or evacuated by the rectum. The addition of chloride of 
sodium to milk impedes or delays the solid curdling by rennet, 
— a physiological fact which explains the usefulness of salt in 
every kind of infant food. For in vegetables, and mainly in 
farinacea, the disproportion of potassium and sodium is still 
more evident than in milks. 

Souring of milk is prevented by boiling, mainly through the 
expulsion of a large quantity (three per cent.) of gases (car- 
bonic acid, nitrogen, and oxygen) contained in the milk when 
it leaves the udder, and by the destruction of parasitic growths. 
Thus I have always advised to boil the milk destined for the use 
of a baby as soon as obtained, fill it hot into bottles, containing 
from three to six ounces, up to the corks, close them tightly, 
and preserve them inverted in a cool place. Whenever a meal 
is to be prepared, the milk thus preserved should be heated 
again up to or near the boiling point, — preferably in a water- 
bath. That process should be repeated perhaps several times a 
day; while one bottle is being heated, the others may undergo 
the same procedure, for every boiling interrupts the beginning 
of lactic acid or other decomposition. The sterilization (or 
pasteurization) of milk in Soxhlet's apparatus, manufactured 
for that special purpose, and introduced in New York by 
A. Caille, is a still better procedure. Milk properly sterilized 
will keep one or more days, but for general use among those 
who cannot obtain or pay for the patented apparatus my 
method will suffice under ordinary circumstances and for peo- 
ple with the most ordinary intellect. 



376 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

A certain amount of starch is digested at the very earliest 
age, for saliva is secreted at that time. Its effect persists in 
the stomach as long as the percentage of hydrochloric acid in 
the gastric secretion does not surpass 0.06; within the first 
half -hour of the digestive process there is none at all but or- 
ganic (mainly lactic) acid only. Thus, though starch pass the 
oral cavity rather quickly, it will still undergo its change into 
dextrin in the stomach. In many abnormal conditions this 
digestive change lasts a still longer time; thus in fevers, severe 
gastric catarrh, and in dilatation of the stomach. These are 
the very conditions in which farinaceous foods are best toler- 
ated, for the reasons that the diastatic effect of the saliva is not 
disturbed, and that albuminoids could not be digested because 
of the absence in these conditions of hydrochloric acid (and 
pepsin). In all normal and many morbid conditions the pres- 
ence of certain quantities of amylaceous foods has some more 
functions. Besides being nutritious in its own way, starch 
serves to dilute cow's milk, to reduce the percentage of casein 
in the mixture, to prevent the latter from coagulating in large 
masses, and thus to render it more digestible. The reasons 
why I prefer in most instances either barley or oatmeal, or in 
others gum-arabic or gelatin, and reject condensed milk, etc., 
have been given above.* 

F. A. Hoffmann, in "Lectures on General Therapeutics," 
Leipsic, 2d ed., 1888, p. 223, says in connection with the rules 
on infant feeding, annually published by the New York Health 
Department, which he copies, "Unless woman's milk can be 
had there is a great danger in the probability that the sensitive 
intestinal tract be supplied with injurious material. For such 
is the very best cow's milk in the cases of very young infants, 
because the mixture of its constituents differs greatly from that 

* It is a source of gratification to the writer to learn that he has 
not been wrong in his practice and teaching. Beidert and Heubner also 
advocate the use of cereals. 



DISEASES OF THE DIGESTIVE ORGANS. 377 

in woman's milk, and its casein is less digestible. Both physi- 
cians and manufacturers have tried to compound substitutes 
for woman's milk, but those only the composition of which is 
known should be noticed by scientific men and recommended. 
Another requisite is this, that such a food must be within the 
means and understanding of everybody, and that a certain 
supervision be possible. Jacobi's treatise in Gerhardt's 'Manual 
of Pediatrics' will be found satisfactory by all those who desire 
to inform themselves on all we know. From my own ex- 
perience, I confirm his recommendations to dilute milk with 
barley or oatmeal water. At present the hope has been ex- 
pressed that all this may be replaced by the sterilization of 
milk, but in practice there will be many impediments and ob- 
stacles. Sterilization can have but one result, — viz., to remove 
the danger arising from the decomposition of milk. But, after 
all, it is cow's milk and not woman's." 

From what I have said I draw the conclusion that as long 
as a baby is not nursed by a healthy woman, the opportunities 
for acquiring some kind of gastric disorder are very numerous 
indeed. Dyspepsia is therefore quite frequent. Its treatment 
consists in more or less abstinence, and in the regulation of the 
diet. As a rule, food should be more diluted than usually. As 
the gastric contents of infants who have been brought up on 
artificial foods is liable to be very acid, alkalies in small doses, 
and frequently administered, have a good effect. Bismuth may 
be added. "When there is vomiting, it must be determined 
whether it is gastric, and from what cause. Those who have 
been in practice know too well how often they have seen menin- 
gitis mistaken for a gastric disorder, and how common is the oc- 
currence of that symptom in the incipient stages of all kinds 
of inflammatory fevers. When all these and the local irritation 
of the stomach (brought on by foreign bodies, such as bulky 
foods, or by the presence of ascarides) and nephritis can be ex- 
cluded, only then the vomiting should be considered gastric 
only. Now and then abstinence only; or the drinking of warm 



378 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

water, or warm mustard water, to facilitate vomiting; or alka- 
lies (bicarbonate of sodium, magnesia, carbonate of calcium), or 
alkalies with bismuth; or resorcin to disinfect the contents; 
or dilute hydrochloric acid for disinfection and to correct the 
nature of the gastric acid; or the washing out of the stomach 
with warm water, or salt-water (6-10 : 1000), or with a bicar- 
bonate of sodium (1 : 100-200), or a resorcin (1 : 50-100) solu- 
tion; and, finally, after the stomach has been freed of its injuri- 
ous contents, small doses of opium, from one-half to one and a 
half milligrammes (one one-hundred-and-twentieth to one- 
fortieth grain), every hour or every two hours, or its equivalent 
in morphine or codeine, will prove satisfactory. Protracted and 
obstinate vomiting I have seen getting well with small doses of 
arsenous acid, from a thousandth to a four-hundredth part of a 
grain every hour or every two or three hours, according to the 
age of the patient or the individual indications of the case. 
Small doses of ice-water or, better still, small ice-pills repeated 
every five or ten minutes will answer in many instances. Ef- 
fervescent drinks, iced, such as small doses of Apollinaris, 
Seltzer, or Vichy, or champagne, may do well in certain cases, 
but will do so less frequently and less happily than in most 
adults under the same circumstances. 

2. Acute Gastric Catarrh. 
When it is produced by injurious ingesta, these ought to be 
removed. If vomiting have not occurred spontaneously, or not 
sufficiently, it should be produced by the above-mentioned 
drinks, tickling the fauces, friction of the precordial region, 
ipecac, — the syrup is very often an unreliable preparation, — or 
other emetics. In cases of great urgency only the subcutaneous 
use of apomorphine may be resorted to. The mildest (and quite 
safe) way of emptying the stomach is by irrigation. Purgatives 
must not be given in the beginning; large enemata will act 
more favorably. They may consist of warm water, warm water 
with antispasmodics, such as assafcetida, or with stimulants, 



DISEASES OF THE DIGESTIVE ORGANS. 379 

such as turpentine. After a day or two a purgative dose of calo- 
mel will answer. Fever, unless it be high, requires no special 
treatment; in urgent cases only antipyrin may be given, either 
by mouth or rectum or subcutaneously. Tendency to convul- 
sions requires cold to the head, or cold applications to the heart, 
which will reduce both the irritation of that organ and the tem- 
perature of the blood. A warm bath will often do good, but 
the customary bathing and jostling and tossing of a baby in 
convulsions do more harm than good. Thirst should be re- 
lieved by water, carbonic acid water, or water acidulated with 
hydrochloric acid (1 : 3000-5000). 

No solid food. Milk should be given in small quantities 
only, diluted with water, or lime-water, barley-water, or upon 
Kudisch's plan (dilute hydrochloric acid 1, water 250, milk 
500). Vomiting is to be treated on the plan detailed above, 
predominance of acids by alkalies, constipation rather by cal- 
cined magnesia in small and frequent doses than by drastics. 
The aqueous tincture of rhubarb, in doses of from ten to thirty 
minims every few hours, will prove very satisfactory in many 
cases. 

3. Gastritis. 

Severe forms of gastritis — the corrosive, diphtheritic, and 
suppurative varieties — require cold applications to the epigas- 
trium, and opium in the most available form; in the beginning, 
morphine subcutaneously. The corrosive form demands neu- 
tralization of the poison first: salt-water for nitrate of silver, di- 
luted acids (vinegar) for lye, alkali (chalk, magnesia, baking 
soda, soap) for acids, sulphate of sodium or oil for carbolic acid, 
egg, water, and milk for corrosive sublimate, etc. All of these 
require a total abstinence, which may be continued for more or 
less time. How long it ought to be endured depends on the 
condition of the patient and the good judgment of the medical 
adviser. Adults will bear it many days, and infants and chil- 
dren from twelve to thirty hours. If such an absolute rest be 
demanded longer than this period, nutritive injections into the 



380 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

rectum should take the place of feeding by the stomach. The 
rectum and the rest of the large intestine digest no albumin 
and emulsionize no fat, but they transform starch into dextrin, 
and cane-sugar into grape-sugar; moreover, they absorb pep- 
tones of every kind, egg, emulsionized fat, and starch. 
(See p. 57.) In all cases of rapid elimination of water by 
vomiting, or of utter exhaustion in gastro-intestinal catarrh 
with imminent thromboses in the small cerebral veins ("hy- 
drencephaloid"), the hourly or bihourly injection of salt-water 
(the usual strength) into the rectum in doses of an ounce or 
much more will fill the blood-vessels and restore circulation. 

4. Chronic Gastric Catarrh. 
It is sometimes dependent on or interrupted by acute ca- 
tarrh; the attacks of the latter must therefore be promptly 
relieved. The several causes of chronic gastric catarrh have 
their own indications. Both in adults and children venous 
congestion resulting from pulmonary or cardiac diseases will 
give rise to it; thus in many cases digitalis in small doses, con- 
tinued a long time, will be the remedy or one of the measures 
of relief. Sedentary life must be avoided, school-hours and 
private lessons kept within reasonable limits, and regulated by 
the meals rather than that these should be controlled by the 
former. Masturbation must be watched: I have seen it to be 
the cause of gastric disturbances exactly as in adolescence. 
Diet and food want attention. Most children eat too much, 
and many too irregularly. Solid food is to be given but 
scantily; no sweets, no fat. Eating must be slow and mastica- 
tion careful. Toasted bread or stale wheat bread, milk diluted 
with cereals or according to the muriatic acid plan (Rudisch), 
or peptonized (but not to bitterness), — everything of moderate 
temperature or hot, — will answer. Slowness of digestion, 
with heavy sensation about the epigastrium, demands ad- 
ditional chloride of sodium, bicarbonate of sodium, efferves- 
cent alkaline drinks; fermentation indicates resorcin, or 



DISEASES OF THE DIGESTIVE ORGANS. 381 

creosote in doses of from one-quarter to one-half of a drop. 
A few grains of salicylic acid diluted in large quantities of 
water (1 : 500-1000) may also be tried. Khubarb and magne- 
sia, rhubarb and bicarbonate of sodium, tinctura rhei aquosa, 
render excellent service. When there is a great deal of mucus, 
dilute hydrochloric acid with small doses of pepsin are indi- 
cated. When the tongue is thickly coated, with eructations, 
chloride of ammonium (half a gramme to one gramme daily) 
with tinctura rhei aquosa; the tendency to vomit and pain de- 
mands bismuth, in older children Carlsbad, Congress, or 
stronger (bitter) waters. These measures may be continued 
for a long period; bismuth may be given indefinitely in small 
doses; sulphate of zinc can be administered (doses from one- 
twenty-fifth to one-sixteenth of a grain = 2-4 milligrammes 
every few hours) a long time, nitrate of silver (doses of one- 
thirtieth or one-fifteenth of a grain = 2-4 milligrammes 
several times daily) for not more than a week in succession. 

Occasionally the irrigation of the stomach is resorted to 
with advantage, and may be repeated. 

5. Dilatation of the Stomach. 
When it is met with in adults, it dates not infrequently from 
infancy or childhood. Its therapeutics is mostly controlled by 
its etiology, and its success in an individual case must depend 
on its causes, which may be numerous: over-feeding in general 
and with amylaceous material in particular; rhachitis with con- 
secutive muscular debility; voracity, imperfect digestion, and 
gas inflation; catarrhal inflammation with diminished absorp- 
tion; general muscular incompetency, as in anaemia and con- 
valescence; congenital imperfection or partial absence of mus- 
cular tissue in the wall of the stomach; hypertrophy and total 
or partial obstruction of the pylorus; or peritoneal adhesions 
of the stomach resulting in a triangular or quadrangular shape 
of the dilated organ. Many of these causes cannot be relieved; 
for instance, the congenital hypertrophy of the circular (in a case 



382 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

of Finkelstein's the longitudinal) muscular layers of the pylorus, 
which may even lead to a dilatation of the oesophagus. Death 
occurred in the known cases between the third week and the 
sixth month. In those which are amenable to treatment, this 
is prominently that of chronic catarrh. Though it be success- 
ful, it cannot positively effect the total diminution of the ex- 
cessive size (large curvature about the level of the umbilicus, 
and the lateral boundaries beyond the linea alba and the middle 
axillary line). 

Antifermentatives should be given, such as bismuth, nitrate 
of silver, calomel, or resorcin; all of these in small, but long- 
continued, doses. The quantity of food taken at once should 
be small; the meals should be numerous. Nothing should be 
given that is apt to ferment, like fat and great quantities of 
starch; a certain amount is digested; when too slowly, taka- 
diastase may be tried. Large_amounts of fluid should not be 
given. Milk in small quantities may be given often. Diarrhoea 
may require gallic acid and other astringents; it depends upon 
the condition of the stomach; indeed, most cases of consecutive 
diarrhoea will be best treated by attending to the stomach. Raw 
beef is among those articles of food which are most easily di- 
gested, and beef peptones in small quantities are very useful. 
Raw milk is not so easily digested as boiled. Peptonized milk 
and Rudisch's preparation should be tried. A bandage should 
be worn about the abdomen. The faradic and galvanic cur- 
rents can be used with advantage. According to Ewald, elec- 
tricity and massage accelerate the passage of chyme into the 
intestine. It seems to me, however, that it is questionable 
whether digestion was improved by them, for it may be that 
both of these applications resulted in premature opening of the 
pylorus, before the gastric digestion was finished. Einhorn's 
method of using the electric current in the interior of the 
stomach is hardly applicable to infants and children. Prepara- 
tions of nux vomica — the tincture — or strychnine in three daily 
doses of from one-one-hundred-and-twentieth to one-sixtieth 



DISEASES OF THE DIGESTIVE OEGANS. 383 

(J-l milligramme) of a grain each will improve the muscular 
tone of the stomach. When the dilatation of the stomach de- 
pends on adhesions, operative procedures may be considered. 

6. Nervous Dyspepsia. 

Its therapeutics must be simple; its effect is not very en- 
couraging. Food should be digestible and sufficiently copious. 
Purgatives should never be given; enemata must take their 
place, if required. Bitter tonics, country and sea air, cold bathing 
or sponge-baths, electricity, one large electrode being applied to 
the stomach and another to the spinal column, are indicated. 
In these cases, which are not quite rare among older children, 
particularly those with early and obstinate chorea and' other 
symptoms of anaemia and "neurasthenia," mild preparations 
of iron and of arsenic are among the very best remedies, and 
should be continued a long time. Training, arsenic, and hy- 
drotherapy will relieve many an obstinate case by improving 
general health and will-power. 

7. Gastric Ulceration. 

With or without hemorrhage, it is not quite uncommon in 
children of from seven to thirteen years. Fatal hemorrhages 
have been observed, by me and others, even in infants. Hemor- 
rhage requires absolute rest in bed, ice-bag to the epigastrium, 
morphine under the skin in appropriate doses, ice-pills, ligature 
of the lower extremities to compress veins, for half an hour 
only; if tolerated, acetate of lead may be given. No matter 
whether the cause may be found in an embolic process, or a 
chronic catarrh of long standing, or a local injury (caustic or 
foreign bodies, stones, a safety-pin in a baby of eight months), 
the circulation in the parts is interrupted and the normal alka- 
linity of the tissues destroyed.. Thus these are constantly ex- 
posed to the injurious effects of the gastric acids, similarly to 
what occurs in the dead body when the effect of the acids on 



384 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

the non-secreting gastric surface results in softening and per- 
foration of the wall ("gastromalacia"). 

Thus the first indication is to keep the stomach and duodenum 
as alkaline as possible, at all events between meals. Now, the 
introduction of any food will give rise to the secretion of gas- 
tric juice, which is first lactic, afterwards hydrochloric acid; a 
certain amount of these is required for normal digestion. 
Whatever there is, however, in the stomach of unnecessary 
acid or acids, which are not required for the physiological pro- 
cess, particularly the acetic, the butyric, caprylic, or only an 
excess of lactic acid, must be neutralized. An occasional dose 
of an antacid is not sufficient for that purpose, but it must be 
given regularly, and for a long time. I generally give the doses 
at intervals of two hours. I also give a dose a few minutes be- 
fore each meal to neutralize every abnormal acid, no matter 
whether the patient is an adult or a child. 

Which antacid is to be selected, — the potassium, sodium, cal- 
cium, or magnesium salts? Of the latter, I prefer calcined 
magnesia to the carbonate, to obviate the expulsion of free 
carbonic acid into the stomach. I use it frequently, but 
rarely (for a child) in larger doses than from eight to ten or 
twelve grains (0.75) daily. A small part of this, say one grain 
(0.06), is taken every hour or two, before meals, mostly in water, 
which should not be too cold; hot water is even better. More 
than that quantity is seldom tolerated, because of diarrhoea 
caused by it; still, its purgative effect is very welcome in pa- 
tients suffering from constipation; these may take larger doses. 
When the above quantity does not suffice to neutralize the 
acids, or it is feared lest more magnesium may cause diarrhoea, 
it may be combined with the carbonate or the phosphate of 
lime. Sodium bicarbonate does not take the place of the cal- 
cium and magnesium so readily, inasmuch as it also appears to 
promote the secretion of gastric juice. Thus, in most cases, I 
use magnesium or calcium with or without bismuth, or such ad- 
juvants, if any, as may appear to be indicated for other reasons. 



DISEASES OF THE DIGESTIVE ORGANS. 385 

The addition of small doses of an opiate is indicated (only) 
when the intense motory action of the stomach is to be quieted. 

This medicinal treatment must be continued for weeks or 
months; without it I do not see gastric or duodenal ulcers 
getting well. 

The Carlsbad waters, and salines in general, owe their effect 
partly to their neutralizing and partly to their purgative influ- 
ence. 

The effect of lime-water is illusory, if given for the pur- 
pose of neutralizing the acid, unless in sufficient quantities. 
Otherwise it is a failure because it contains only a single grain 
to nearly two nuidounces (50.0) of water. But when added to 
cow's milk in sufficient quantities (1 : 2-3) it certainly makes it 
more digestible. 

The very function of the diseased organ involves danger. 
Both the stomach and the duodenum should be kept as idle 
as possible, and their labor should be made easy. Indigestible 
food must not be given, and solid food must not be allowed. 
Most older children tolerate boiled milk, strained oatmeal, bar- 
ley gruel, stale wheat bread, and a few also raw beef. Some 
take nothing but boiled milk, or buttermilk, or koumiss. Many, 
particularly convalescents or adults, will tell you that they do 
not digest milk. That may be true, but then they gulped it 
down, and it formed in the stomach a large cheese-cake that 
was not afterwards dissolved and digested. They should boil 
their milk in the morning and heat it several times during the 
day almost to the boiling point, or should pasteurize it for the 
day. They should add a small quantity of table salt to it; also, 
in case the stomach is very acid, some bicarbonate of sodium, 
or calcium, or magnesium. They should not drink their milk, 
but pour it into a plate and sip it with a spoon. Thus prepared, 
they will digest it, particularly when it is not quite cold. In 
fact, many require their meals warm or hot. 

For the purpose of easier digestion, milk may be peptonized, 
according to Fairchild's directions; or it may be rendered 

25 



386 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

more digestible by the process recommended by Dr. Rudisch, 
or mixed with farinaceous decoctions as recommended above. 

With an alkaline condition of the surface and an innocuous 
diet, the ulcers have an opportunity to heal. Their recovery 
may be aided by the administration of nitrate of silver. A 
child may take from one-thirtieth to one-twentieth of a grain 
(2-3 milligrammes) in a tablespoonful of distilled water four 
or five times a day; if possible, on a fairly empty stomach. Or 
a smaller quantity may be given in a pill with or without a 
small dose of opium, say one-sixtieth to one-fifteenth of a grain 
(1-4 milligrammes) in each pill. Sometimes I give but a single 
dose at bedtime, in addition to the alkaline treatment. Nitrate 
of silver must not be given beyond a reasonable time, to avoid 
argyria. 

The tincture of iodine, in doses of from one to three drops 
for the adult, of one-half to one drop to a child, well diluted 
with water, has often been recommended. Its action is prob- 
ably antifermentative here as in chronic gastric catarrh. 

When there is much pain and a great deal of acid or other 
secretion, opiates are indicated, mainly those which are very 
soluble. Chloral is tolerated badly. 

Bad cases require rest in bed, particularly those of anaemic 
girls (and women). 

The stomach has a better opportunity to get well when at 
rest than when at work. Thus it becomes necessary, some- 
times, to abstain from feeding by the mouth altogether. Rectal 
alimentation then comes in to great advantage. In conditions 
of such genuine starvation the lymphatics are very greedy and 
absorption from the rectum is very active. 

Ulcer of the stomach, both in the young and old, being fre- 
quently associated with intense anaemia, the result, in these 
as in many other cases, is mistaken for the cause. Then iron, 
the great presumed panacea for anaemia, is often introduced 
into the stomach which cannot digest it, and in its attempts to 
do so, pain, ulceration, and danger are increased, 



DISEASES OF THE DIGESTIVE ORGANS. 387 

F. Intestinal Diseases. 
1. Constipation. 

The catarrhal and inflammatory diseases of the mucous mem- 
brane of the intestinal tract have so many common anatomical 
and pathological features that, for practical reasons, and to 
avoid repetition, I prefer to discuss them under the heads of 
their principal symptoms. Indeed, the acute, subacute, and 
chronic catarrh (enteritis), cholera nostras, follicular enteritis, 
even membranous enteritis, are but varieties of the same 
process, differing only in individual acuteness, or extension, or 
in its localization in the epithelium, muciparous follicles, or 
lymph-bodies, or in innervation. 

The main symptoms observed in diseases of the intestinal 
tract are constipation (less frequent) and diarrhoea. 

The therapeutics of constipation depends on its etiology and 
its degree. In no case should the diagnosis be made without a 
thorough examination, which must be manual in many. The 
abdomen may be painless, but it is mostly inflated. Faeces 
come away in large lumps or in small and broken pieces. The 
liver and spleen may be displaced, the former turned in such a 
way as to protrude its edge and posterior surface. The abdom- 
inal veins may be enlarged, the appetite diminished; vomiting 
is sometimes met with, occasionally also intervening attacks of 
diarrhoea which are the result of the irritation produced by the 
hardened faecal masses contained in the colon. 

Actual constipation should not be mistaken for an apparent 
one, which is observed in infants that have a small movement 
every two or three days only. The baby is emaciated, atrophic, 
not always fretful. In it the scantiness of defecation is the 
result of lack of food, and the alleged costiveness is speedily 
remedied by the furnishing of a sufficient quantity of appro- 
priate nourishment. 

Among the foremost causes of constipation is mechanical 
obstruction, brought on by cystic and other tumors, imperfo- 



388 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

ration, hernia (pervious or incarcerated), intussusception and 
twisting of the intestine, or by a peculiar condition of the 
sigmoid flexure described by me in the Journal of Obstetrics 
of 1869. The cases of constipation depending on the undue 
length of the descending colon and on the multiplicity of flex- 
ures which compress each other and thus obstruct the passage 
are quite numerous in every physician's practice. These cases 
of constipation are apt to last up to the sixth or seventh year 
and require constant attention, but medicinal treatment should 
be avoided, unless it be required by intestinal autoinfection. 
The faeces may be so hardened and immovable as to necessitate 
their extraction from the rectum by means of the finger or a 
spoon. Now and then in this, also in other varieties of consti- 
pation, the hard masses are felt in the abdomen, and have been 
mistaken for tumors. On no account should purgatives be 
given as a regular thing, but an enema should be administered 
daily for many years in succession. At the above-mentioned 
age the relation of the several parts of the intestinal tract to 
one another becomes more normal, and the necessity for me- 
chanical interference ceases accordingly. 

An improper condition of food is a frequent cause of con- 
stipation. Excess of casein is relieved by diminishing its quan- 
tity, by replacing the milk of a cow by that of a wet-nurse, 
the white and heavy one of a wet-nurse by the thinner and 
more bluish one of another woman, or by reducing the amount 
of casein in artificial food to one per cent, or less. Besides, the 
milk thus reduced should be mixed with a glutinous (farina- 
ceous) substance; oatmeal, to remedy constipation, is preferable 
to barley or any of the rest. Large amounts of starch must be 
avoided. Milk and artificial food will often lose their consti- 
pating effect by the addition of cane-sugar. Babies at the 
breast are frequently cured of constipation by the administra- 
tion of one or two teaspoonfuls or a tablespoonful of water, or 
oatmeal-water, thoroughly sweetened, before each nursing. 

Many preparations kindly supplied by the ever-watchful and 



DISEASES OF THE DIGESTIVE ORGANS. 389 

humanitarian trade contain large quantities of phosphates. 
They are apt to pass in part into the intestine undissolved and 
unabsorbed. So will large doses of bismuth. Thus constipa- 
tion may follow their use. The treatment of such a case is 
plainly indicated; likewise of those which are the direct result 
of the administration of astringents and opiates. The omission 
of such a medication is the first condition of a cure. 

Constipation is often dependent on the partial absence or 
the viscid condition of intestinal mucus. This is so in fevers, 
now and then in chronic enteritis (intestinal catarrh), mainly 
of the lower bowels; also when there is too large a secretion 
from the skin and (or) kidneys, and when too little water is 
introduced into the circulation. I have repeatedly emphasized 
the fact that most infants are given less water than they re- 
quire. In "membranous enteritis" the large amounts of mucus 
discharged through many weeks or months, and sometimes 
years, are less frequently found in children than in hysterical 
(men or) women. That mucus is no longer viscid, but appears 
in the shape of membranes, sometimes in casts, but consists of 
nothing but mucus, with more or less traces of fibrin. In this 
condition, also, there is constipation as regards faeces; the dis- 
charges may be quite frequent, however. Large injections of 
warm water with one or two per cent, of bicarbonate of sodium 
should be made daily, at least once daily. Xow and then a mild 
purgative (castor oil) is advisable. But the condition which is 
mostly found in neurotic children, or such as belong to a neu- 
rotic family, will not be relieved except through persistent at- 
tempt at improving the general condition by hydrotherapy and 
other general tonics. 

Incomplete peristalsis resulting in costiveness may depend 
on a morbid condition of either the muscle both of the in- 
testine and the abdominal wall, or its innervation. Early 
rhachitis shows its effect in producing muscular incompetency; 
babies with regular evacuations after birth will become costive 
in their second and third month, and remain so although they 



390 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

are alleged to "look the picture of health." Not rarely 
rhachitis will make headway in muscles, epiphyses, and diaph- 
yses, even in cranial bones; while the weight of the patient 
does not decrease, his skin feels soft and flabby, the limbs and 
trunk are rotund though bleached. Indeed, there are many 
in whom constipation is the very first symptom of rhachitis. 
In all of them it is self-evident that constipation cannot be 
relieved permanently except by a thoroughly successful anti- 
rhachitical treatment. Sedentary habits of school-children 
have the same effect in producing constipation. It is relieved 
by change of habit and plenty of physical exercise, and addi- 
tional fruit diet, but purgative medicines, given persistently, 
render these cases worse. The binding effects of chronic peri- 
tonitis, either general or local, must not be combated with 
purgatives; a snug bandage round the abdomen gives support 
and tone to the bowels, and an enema, given every day for 
months in succession, prevents accumulation and its conse- 
quences (dilatation, disorder of circulation, septic absorption). 
Universal emaciation and atrophy resulting in constipation has 
its own indications, and chronic cerebral disease (hydro- 
cephalus) may require such local and medical treatment as has 
been detailed above. 

In all forms of constipation in infants or children few 
medicaments ought to be used. As there is so often an excess 
of acid in the gastric and even intestinal contents, calcined 
magnesia finds its twofold indication. It may be given in 
many small doses or a single large one which need not exceed 
five or ten grains (0.3-0.6) a day. Doses of a grain or two 
grains may be continued for many days and repeated from three 
to six times daily. Ehubarb acts well when combined with it 
for the purpose of overcoming protracted costiveness. Eectal 
injections may be given from the common fountain syringe, 
the nozzle of which should be introduced beyond the two 
sphincters. In some cases it is desirable to introduce the in- 
strument to a greater distance; an elastic catheter attached to 



DISEASES OF THE DIGESTIVE ORGANS. 391 

the nozzle may be used for that purpose, but the very condition 
of the sigmoid flexure, detailed above, renders the introduc- 
tion of the instrument beyond the very beginning of the sig- 
moid flexure a perfect illusion in many cases. It happens quite 
often that an elastic or flexible tube, when introduced to or be- 
yond the third sphincter, bends upon itself and reappears at the 
anus. To facilitate the entrance of the liquid into and beyond 
the sigmoid flexure the injection should be made gently and 
slowly while the pelvis of the infant is raised. 

To facilitate the downward movement of faecal masses and 
to stimulate peristalsis, friction and kneading (massage) may 
be resorted to. Kneading must be performed with the palm 
of the hand, gently and persistently; or gentle thumping with 
the closed hand and friction are best commenced in the right 
side and continued over the epigastrium and down the left side, 
in the course of the colon. Great caution and judgment must 
be used because of the frequency of local chronic peritonitis, 
which, when disturbed, causes subacute or acute exacerbations. 

Electricity has been used successfully when constipation was 
the result of insufficient peristalsis. E. Schillbach found that 
the several portions of the intestinal tract respond differently 
to the application of the faradic and galvanic currents.* The 
latter appears to have a stronger effect than the former. Local 
contractions result from the negative pole (cathode), peristaltic 
waves from the positive (anode). Thus for the relief of chronic 
constipation depending upon incompetency of muscular action 
the former ought to be applied to the interior of the rectum, 
the latter over the abdomen, along the colon. 

In the cases of persistent constipation depending upon an 
insufficient muscular action of the intestine now and then medi- 
cation may appear required. I have treated a number of oases 
of the kind with nux and (or) physostigma, adding some purga- 
tive extract. A little boy with a decidedly rhachitical history, 
three years old, took three times a day a sixteenth (4 milli- 

* See Meltzer, p. 313. 



392 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

grammes) of a grain of each. — extract of nux vomica, extract 
of physostigma, and compound extract of coloeynth — for many 
weeks in succession. But cases of the kind are, and should be, 
exceptional. As an occasional purgative, for the purpose of re- 
lieving the intestinal tract of indigestible and injurious masses, 
castor oil is probably the best and mildest; a few grains of calo- 
mel, or less, will act both as a purgative and an antifermenta- 
tive. The compound powder of liquorice will take the place 
of oil, when the latter is not tolerated, or is objected to; also 
the fluid extract of rhamnus frangula. 

Among the drastics, all of which are irritants, rhubarb and 
aloes are probably the mildest, and are tolerated a long time in 
succession. Of the salines, chloride of sodium is the simplest. 
Its main action is osmotic; besides, it occasions thirst and 
thereby induces the ingestion of a large amount of water. The 
continued use, however, of salines irritates the mucous mem- 
branes. The combination of the sulphate of sodium with that 
of magnesium and chloride of sodium has a mild and happy 
effect. 

A frequent accompaniment of constipation is colic. Its 
causes are, besides constipation, fermenting food, gastrointes- 
tinal catarrh, the presence of ascarides in large numbers, reflex 
spasm produced by cold feet and chilled skin, diminished 
tonicity of the muscular layers of parts of the intestine (in 
general anaemia and rhachitis during early infancy), and, 
finally, chronic peritonitis, which resulted in adhesions, or such 
local changes in the walls of the intestine as will produce local 
contractions or dilatations. Thus as the etiology of colic varies 
so much, the treatment must vary in order to be rational and 
effective and adapt itself to the cause. Its symptomatic treat- 
ment will often require either an enema or a purgative medi- 
cine, antispasmodics or narcotics (assafcetida, opium); they are 
apt to give speedy relief. Gentle friction of the abdomen, the 
application of dry heat (flannel, hot plate, hot sand-bag), and 
the administration of hot aromatic teas freshly prepared (fen- 



DISEASES OF THE DIGESTIVE ORGANS. 393 

nel, anise, catnip, German chamomile), a few drops of essence 
of peppermint in a teaspoonful of hot water, or the injection 
into the rectum of large quantities of aromatic teas, at a tem- 
perature of 100° or more, will do good; great care should 
be taken lest atmospheric air enter the bowel. 

2. Diarrhoea. 

Diarrhoea is always dependent on, or connected with, surface 
changes of the intestinal mucous membranes, from a simple 
catarrh to ulceration. Catarrh may be localized, but is gen- 
erally very extensive. It may descend from the stomach, 
ascend from the rectum and colon, or originate in any part of 
the small intestines. 

The treatment of diarrhoeal diseases depends in part on the 
locality, in part on the etiology of the individual affection. No 
"specific" treatment will ever do good, not even the modernized 
stomach-pump sticking conceitedly out of the coat-pocket of 
the delighted medical man who appears eager to emulate the 
midwife of our mothers with the rectal syringe under her arm 
as her emblem. 

The causes of diarrhoea are various. Food in improper quan- 
tity or quality, mostly unsuitable artificial food, is among the 
principal causes. But even mother's milk may cause it, as is 
proven by the fact that there are babies who, while falling sick 
at the breast of one woman, may recover at that of another. 
Mothers who are sick or convalescing, or subject to very strong 
emotions, those who nurse too often, who suffer from tubercu- 
losis or syphilis, who are pregnant, some when they are men- 
struating, and all anaemic persons, secrete an improper milk. 
The colostrum furnished immediately after childbirth is apt to 
give rise to diarrhoea. Milk containing too much fat is the 
principal cause of what has been described as "fat diarrhoea," 
by German authors mostly; that containing salts in super- 
abundance, mainly in anaemia of the mother, is liable to pro- 
duce the same effect. 



394 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

The amount of food introduced may be too large either ab- 
solutely or relatively; the latter when the secretion of gastric 
fluids is insufficient, thus facilitating gastric fermentation in 
place of digestion; or when the flow and activity of pancreatic 
juice, limited at a very early age, is still more interfered with 
by a diseased condition of any kind, and fever of any descrip- 
tion. 

The infant intestine is not controlled to the same extent as 
that of the adult by emotional influences; but local irritation 
is a frequent cause of diarrhoea, and the organ is very sensitive 
to the diminution or increase of atmospheric moisture and 
heat. It is quite probable that the overheating of the general 
surface affects the blood, the duodenum, and the general ner- 
vous system similarly to what is observed after serious burns. 

The mucous membrane with its lymph-vessels and follicles is 
easily irritated by such results and companions of fermentation 
as phenol, indol, skatol, and bacteria; by the alkaline salts 
formed through the frequent (normal and abnormal) prev- 
alence of acids in the upper part of the intestinal tract; by 
the direct influence of purgatives, occasionally by even the very 
smallest doses of arsenic and mercurials, though, indeed, the 
latter are tolerated very much better by the very young than 
by the adult; and by sudden exposures to a cold temperature. 
It is also liable to suffer long from the results of typhoid fever, 
dysentery, and occasionally from severe attacks of malaria. 

Disturbances of the circulation depending upon diseases of 
the liver, lungs, or heart, predispose to passive hyperemia of 
the intestine and to diarrhoea. Indeed, when it does occur in 
these diseases, it is an ominous symptom. In no case of intes- 
tinal disease ought the diagnosis to be considered complete or 
a prognosis ventured upon, unless the liver, and particularly 
heart and lungs, have been examined with great care. 

The variety of causes suggest a number of different treat- 
ments. Disorders of circulation should be regulated while the 
local disease is attended to; ulcerations of the intestines are to 



DISEASES OF THE DIGESTIVE ORGANS. 395 

be treated on some such method as has been suggested in pre- 
vious remarks on dysentery; the skin, if there be fever, should 
be kept cool by bathing or sponging; the air-supply should be 
cool and plentiful. 

Most cases of intestinal catarrh (with or without gastric ca- 
tarrh) and diarrhoea depend on the administration of improper 
food and the derangement produced by it. That should be 
changed immediately. When the process of fermentation is 
still limited to, or going on in, the stomach, or the stomach 
still contains injurious masses, these ought to be brought up. 
In such a case the sound judgment of the practitioner has to 
decide whether emesis is still useful, or whether the stomach 
ought to be irrigated and washed out. Most cases of "gastro- 
enteritis v are pre-eminently enteritis; therefore the claim that 
the washing out of the stomach must not only take place in 
every case, but is the almost infallible remedy in the very worst 
class of cases, will have no other result but that of discrediting 
that useful procedure in the eyes of those who are inclined to 
believe implicitly in the value of "new" methods and the pre- 
tentious claims of short-sighted enthusiasts. If we were to 
believe some of the loud talk of the journals, and the reporter's 
columns in the secular press, gastro-intestinal catarrh would 
soon be "one of the lost arts." 

In fact, the injurious element is in most cases beyond the 
reach of the stomach-pump; indeed, the latter cannot remove 
anything but what is dissolved or suspended; the expulsion of 
large masses, curd particularly, through an elastic catheter is 
out of the question. 

The role played by bacteria in the stomach and intestines is 
probably great, the class of the schizomycetse is numerously 
represented alike in the healthy and the diseased intestine. 
Even within from four to eighteen hours after birth there are 
large numbers of bacteria, cocci, bacilli subfiles, and bacteria 
coli communia (Escherich) in the remnants of digested milk; 
the latter microbe in the large intestines. How many are intro- 



396 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

duced into the stomach immediately after birth, by the air 
swallowed by the newly-born, cannot be determined. Besides 
those enumerated above, there is the bacterium lactis aerogenes 
which is credited with the decomposition of milk-sugar into 
lactic acid, carbonic acid, and hydrogen, thus giving rise to 
most of the gases constantly present within the intestinal tract. 

The presence of immense quantities of micro-organisms 
need, however, prove nothing in regard to the etiology of dis- 
eases, for they are found in the healthy state as well, as also 
in those morbid conditions in which the cause of death cannot 
be attributed to the presence of parasites or the usual patho- 
logical changes. Thus in arsenical poisoning the intestines 
are swarming with saprophytes. To what extent bacteria, and 
which of them, are the actual causes of diarrhceal diseases is 
still debatable, in spite of Baginsky's and Booker's labors. 
During lactation, in the young child, the upper part of the 
small intestine holds bacterium lactis aerogenes, the ileum and 
colon bacterium coli commune. During the summer diarrhoeas 
both varieties increase in numbers, and swarm over the whole 
intestine; thus in neither of them is there anything specific 
or etiologically important. In protracted cases of catarrhal 
enteritis leading to ulceration, according to W. Booker, strepto- 
cocci are found in large numbers; in more than half the cases 
proteus vulgaris is found, mainly in the stomach and the colon; 
the putrid odor appears to depend on its presence. Both these 
microbes may emigrate to the abdominal viscera, the lungs, and 
the blood, thus, if they be causes of the original disease, estab- 
lishing a general, constitutional malady. To judge from the 
undoubted occurrence of diarrhceal diseases by contagion 
ascending through the anus (soiled diapers, fingers of nurses, 
contact in institutions), bacteria must be credited with being 
more than companions, — that is, direct causes and sources of 
the local and the general affections. 

The intestine may be emptied either by purgatives or ene- 
mata; the former act upon the whole length of the intestine, 



DISEASES OF THE DIGESTIVE ORGANS. 397 

the latter upon its lower portion. Castor oil, so common in 
domestic practice, deserves all the credit given to it. It acts 
mildly and speedily. The addition of opium is not wise; the 
latter may be administered after the former has exhibited its 
effect; the action of the oil must not be inhibited by the seda- 
tive. In many cases a single dose of calomel (one-half grain to 
six) answers better, being both a purgative and antifermenta- 
tive. 

The surplus acids of the stomach — mostly lactic, acetic, and 
butyric — must be neutralized. Magnesium and sodium salts 
must not be selected for that purpose, for they add to the diar- 
rhoea. Calcium salts, the carbonate or phosphate, are prefera- 
ble because they have no such effect, but the additional advan- 
tage of forming with the fat acid an insoluble salt which acts 
as a protection to the sore surface. Doses of about one or two 
grains (0.05-0.1) may be given every hour or two. Besides 
being an antifermentative in general, bismuth (the subnitrate 
or carbonate) binds sulphide of hydrogen, and thus has a favor- 
able effect in frequent doses of from a quarter of a grain to 
two grains. They may be administered with or without the ad- 
dition of opium. If they be given in liquid form, no syrups 
should be added to correct the taste, but rather glycerin, which 
has the advantage of not turning sour. The subgallate is 
credited with still more constipating action. 

To combat the existing fermentation, antifermentatives may 
be given in regular intervals. Calomel, bismuth, alcohol, creo- 
sote, salicylate of sodium, salol, naphthalin, resorcin, bichloride 
of mercury, and others, have been eulogized. To take effect in 
the intestine it appears that those who are not readily soluble 
in the stomach ought to prove more useful. Still, I feel posi- 
tive that resorcin in doses of from a quarter to one-half of a 
grain (0.015-0.03) in solution, or as a constituent of a powder 
containing bismuth, chalk, or (and) opium, given every two 
hours, has rendered me the most valuable services in a great 
many cases. Of the two mercurials I prefer calomel by far, in 



THERAPEUTICS OF INFANCY AND CHILDHOOD. 

doses of from a twentieth to a quarter of a grain (3-15 milli- 
grammes) every few hours. The antifermentative effect of alco- 
hol in the dilution in which we are entitled to give it as a stimu- 
lant, though the sum total of a daily dose may be large now and 
then, is not great; salicylate of sodium is less effective than 
any of the rest, creosote acts more vigorously in the stomach 
than in the bowels, salol is readily taken; naphthalin is objec- 
tionable to many, because of its taste and odor. 

Opium, by its inhibitory effect on reflexes, diminishes hy- 
peresthesia, hyperperistalsis, and hypersecretion. The objec- 
tions to its use in the diarrhceal diseases are theoretical only. 
Doses of from one-tenth to one-third of a grain (6-20 milli- 
grammes) of Dover's powder every two hours, in all sorts of 
combinations, act very well indeed, and may well be considered 
indispensable, when the above indications are to be fulfilled. 
Its time has arrived when the odor of the evacuation begins 
to be normal; but it finds no contraindication in those cases of 
"follicular enteritis" of a chronic nature which exhibit their 
tendency to malodorous discharges for weeks in succession. 

In acute cases, and when the stomach participates in the 
process, astringents, such as lead, tannin, gallic acid, alum, etc., 
are badly borne. In chronic protracted cases they will find 
their indication. Nitrate of silver does better in many cases, 
one-fiftieth to one-thirtieth of a grain (1-2 milligrammes) in 
two drachms of distilled water (dark bottle) every two hours. 
In chronic cases only, coto, from half a minim to a minim of 
the fluid extract, will sometimes act favorably. Tannalbin, in 
daily doses of from four to fifteen grains (0.25-1.0) or more, as 
a powder or in mixtures, is among those modern medicines 
which are highly recommended by some observers, too highly 
by manufacturers. 

Of the stimulants, alcohol may be admixed to food. Bad 
brandy or whiskey contains fusel oil, which is a paralyzing 
agent. Whiskey is therefore preferable with us, because it can 
be obtained in greater purity for less money. It must not be 



DISEASES OF THE DIGESTIVE ORGANS. 399 

administered unless diluted. Camphor is better borne than am- 
monium. It is easily taken when simply rubbed off with glyc- 
erin and suspended in mucilage (one-fourth to two grains every 
one or two hours). The strongest nerve-stimulant of all is Si- 
berian musk. Urgent cases of collapse require one or two grains 
(0.06-0.125) every fifteen or thirty minutes (best suspended in 
mucilage) until six or twelve grains have been taken. A very 
good stimulant in collapse is the injection into the bowels, 
through a long flexible tube (catheter No. 12, English) of hot 
water with not more than five per cent, of alcohol, and one or 
a few drops of tincture of opium. In threatening cases of 
heart-failure strong coffee, hot or iced according to circum- 
stances, by itself or in mixtures, may be used to advantage. 
Cold tea may be tried in small doses, particularly in the chronic 
cases of older children. 

In acute cases of intestinal (or gastro-intestinal) catarrh 
with high temperature, applications of water, of from 60° to 
70° F., to the abdomen will render good service. The cloth 
must be wrung out thoroughly, covered with rubber cloth and 
flannel, and changed when warm. Anaemic children and those 
with much pain require warm or hot applications, which may 
be preceded by a warm bath. Frequent injections of water of 
100° F. or more, with or without an antifermentative, such as 
thymol (1 : 1000 or 2000), answer well in most cases, not only 
in rectal catarrh. In great debility, or collapse, the water 
ought to be from 105° to 112° F., and contain some alco- 
hol and opium, or (and) a teaspoonful of the tincture of 
musk. The addition of gum-arabic to the injection, or the use 
of glutinous decoctions (flaxseed) instead of water has a satis- 
factory influence. Starch injections have the advantage of 
adding to the nutrition of the body by the facility with which 
the colon changes amylum into dextrin, which will be absorbed. 
Part of the injected water will always be absorbed, fill the 
blood-vessels, and may prevent intracranial and other throne 
boses. Indeed, in many bad cases in which the cerebral symp^ 



400 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

toms of the so-called hydrencephaloid condition have made 
their appearance, or are imminent, frequent injections into the 
rectum of a few ounces of warm fluid contribute considerably 
to the restoration of circulation. 

In hot weather doors and windows should be kept open, the 
coolest place selected in the house or neighborhood, day or 
night; for night air is preferable to no, or foul, air; and sea 
air or country air, particularly at some altitude, is superior to 
city air. When in hot weather the body feels hot, it should be 
washed with cold or cool water, or water and alcohol (5 : 1), 
frequently. Cold feet must be warmed by flannels, hot stones, 
hot sand- or water-bags, and gentle friction, and well covered. 

The food-supply must depend on the condition of the 
stomach and of the upper part of the intestine, and also on the 
rapidity of the peristaltic action of the latter. The complica- 
tion of gastritis with enteritis contraindicates the introduction 
of food altogether. Abstinence is better in cases of intense 
vomiting than the use of ice; the latter may quiet the stomach 
for awhile, feel pleasant, but it fills the stomach which ought 
to remain in absolute rest, and excites peristalsis. Babies with 
an irritated stomach tolerate abstinence better than ingesta. 
The ubiquitous beef -tea ought to be avoided; its concentration 
of salts is irritating. If in convalescence it be given at all, it 
should be mixed largely with barley-water or rice-water. 

In all cases of "summer" diarrhoea milk must be avoided. 
Bad cases forbid raw milk, boiled milk, milk in any and every 
shape, for days and longer. Its rapid fermentation contraindi- 
cates the smallest quantities, even in farinaceous mixtures. 
The absence of gastric juice (pepsin and hydrochloric acid) in 
the stomach of a feverish child or of one that is being drained of 
its fluids prevents the digestion of albuminoids. Even mother's 
milk is often not borne to any extent. When milk is again 
tried after a while, it ought to be done very carefully; cow's 
milk thoroughly boiled, or sterilized with six times its volume 
of barley-water at first, the percentage of milk to be increased 



DISEASES OF THE DIGESTIVE ORGANS. 401 

slowly. I repeat: cow's milk, ever so often boiled or sterilized, 
is still cow's milk. Milk may be replaced by the white of egg, 
which should be thoroughly mixed with barley-water, and some 
salt added, and not more (cane-) sugar than is required to make 
the mixture palatable. During the course of a day and night 
the whites of from one to five eggs may be given according to 
the case and age. Severe vomiting and diarrhoea demand, as 
suggested, total abstinence for from two to eight hours or more. 
Afterwards, mucilaginous or farinaceous decoctions may be 
given in small doses at short intervals. A mixture which has 
rendered me very valuable services in the worst cases of vomit- 
ing and diarrhoea, after the period of absolute abstinence was 
terminated, is about as follows: Five ounces (150.0) of barley- 
water, the white of one egg, from one to two teaspoonfuls of 
brandy or whiskey, some salt and cane-sugar; a teaspoonful 
every five, ten, or twenty minutes according to circumstances. 
Mutton broth may be added to the above mixture, or it may be 
given by itself, with the white of egg and some little salt. 

3. Tumefaction of the Mesenteric Lymph-Bodies. 

It is of frequent occurrence. Its results are very serious, 
though the non-absorption of chyle does not depend exclu- 
sively on the functional incompetency of the lymph-bodies. 
Simple inflammatory hyperplasia of the lymph-bodies can be 
more safely prevented than cured. Its original cause is mostly 
a diarrhoea of some form or another. The irritation of a mucous 
membrane always leads to that of the neighboring glands; the 
glands near a nasal catarrh, a stomatitis, a diphtheritic process, 
a pulmonary catarrh, produce secondary adenitis. Thus the 
mesenteric glands near an intestinal catarrh are soon congested, 
and begin to swell. Cell-proliferation accompanies the changed 
circulation; when its original cause — viz., the hyperemia of 
the mucous membrane — has ceased, absorption of the newly- 
deposited material will always take place in the same way that 
the swelled glands of the neck will disappear when a nasal ca- 

26 



402 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tarrh is treated with cleansing and disinfecting injections. As 
soon, however, as the newly-formed cells have been transformed 
into firm fibrous tissue, the possibility of absorption becomes 
less from day to day. Thus, the prevention of mesenteric 
glandular hyperplasia consists in the immediate removal of a 
diarrhoea. Be it ever so mild, it is always a morbid process. Be 
its name ever so innocent (for instance, "dental"), and the 
prejudice in favor of letting it alone ever so strong, it leads to 
anatomical changes which may become permanent in the mu- 
cous membrane and the glands. When a diarrhoea has been 
protracted, it may safely be assumed that the glands have 
undergone chronic changes. Then the cautious administration 
of an iodide, preferably sodium, is indicated, in daily doses of 
from five to fifteen grains (0.3-1.0), according to the age of the 
patient, the severity of the case, and the probable duration of 
the process. It should be continued for weeks, and then may 
be replaced by three daily doses of from five to twelve minims 
of the syrup of the iodide of iron. Morbid processes of any 
kind in neighboring organs may cause glandular swelling. 
Adenoma of the liver in a girl of twelve led to (not adenoma- 
tous, but simply hyperplastic) tumefaction of the periportal 
lymph-bodies and to a very rapid development of ascites 
{Trans. Assoc. Am. Phys., 1897). 

Primary tuberculization of the mesenteric glands is quite 
rare; so is primary tuberculosis of the intestine, in spite of the 
fact that meat (very rarely) and milk containing the bacillus are 
known to be the occasional cause of tuberculosis of the bowels. 
Both are, as a rule, the results, or complications, of general tu- 
berculosis, and in this way they, and tubercular peritonitis also, 
are not uncommon. Thus, the treatment of tubercular tume- 
faction of the mesenteric glands forms part of the measures 
undertaken for the relief of the symptoms of the general in- 
fection, and leaves but little to hope. Still, there are cases in 
which the tubercular nature of the swelling cannot be doubted, 
but still are liable to get well. There are now on record a 



DISEASES OF THE DIGESTIVE ORGANS. 403 

number of cases of peritoneal tuberculosis in which laparotomy 
was performed, either through a mistaken diagnosis or pur- 
posely, with relief to the symptoms, and apparent recovery. 
Indeed, there can be no doubt that a number of cases of peri- 
toneal tuberculosis, in which the diagnosis was hardly dubious, 
improved considerably, either under no treatment at all, or 
under measures calculated to benefit the general tubercular 
condition. Thus, even such cases permit of a hesitation to 
pronounce a fatal prognosis. 

The conditions alluded to must not be mistaken for tume- 
faction of the mesenteric glands from other causes (for in- 
stance, primary lymphoma, the glandular enlargement of leuco- 
cythasmia or syphilis, or sarcoma which occurs primarily, or 
from carcinoma which is met with secondarily in young or 
older children). Lymphoma and sarcoma are positively im- 
proved by the protracted use of arsenic, in increasing doses, 
such as are discussed in a previous chapter. Syphilitic swell- 
ings require the persistent administration of active doses of 
both mercurials and iodides. 

4. Appendicitis. 

It is a very frequent disease in childhood, and much more so 
than colitis or typhlitis not attended with an affection of the 
appendix. Absolute rest and very careful observation of the 
patient by a competent person are required. Even in the 
mildest cases the patient must use the bedpan and urinal, and 
must not be permitted under any circumstances to change his 
position without being aided. The disturbance of an incipient 
peritonitis by mechanical causes is a serious matter; recent 
adhesions are very liable to be torn and give rise to new attacks. 
No purgatives must be given except a dose of oil in those rare 
cases where no evacuation has taken place for some time, and 
the accumulation in the colon of large quantities of faeces is 
considered probable. In these cases, however, a large enema of 
soap and water given at once will mostly fulfil all the indica- 



404 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tions. Thus, I am not at all prepared to advise, with a few 
modern authors, to commence the treatment of appendicitis 
(and peritonitis in general) with the sulphate of magnesium, 
or a large dose of calomel. The injection, however, first of a 
few ounces of olive oil, and afterwards of large quantities of 
soap and water, through a fountain syringe, is again indicated 
after a week or ten days. No stomach washing, no puncturing 
to establish a diagnosis. Opium must be given freely by the 
mouth, rectum, or subcutaneously, in full doses. In almost 
every case ice applications must be made for days to the right 
hypochondrium, and warm applications after many days when 
the fever subsides. The food must be liquid, and given in 
small quantities at a time. The patient must remain in a re- 
cumbent posture for weeks after apparent recovery, and be 
kept quiet even then, for an abscess may be encapsulated and 
perforation may occur. 

A positive diagnosis should be made early. Frequent pre- 
vious pain in the same locality, and intestinal disorders ac- 
companying them, or a similar attack which occurred months 
ago, a very sudden csecal pain with vomiting (or without) a few 
hours or days ago, and illness with fever, perhaps the pres- 
ence already of slight swelling since, leave but little doubt. 
When the diagnosis of appendicitis is established, to say with 
a modern author (Tyson), that the surgeon should be called in 
to decide on the time of operation, is rather rash. Of Biermer's 
one hundred and twelve hospital cases of all ages not operated 
upon, between the years 1874-89, ninety-eight left well and 
nine "relieved." Eelapses took place in seventeen, of whom 
two died. In five many recurrences took place. These figures 
are very favorable, too favorable in my experience, though the 
course is apt to be milder in children than in adults. Hawkins 
reports on two hundred and sixty-four cases with a mortality 
of fourteen per cent.; of those which terminated in abscess 
twenty-six per cent, died, of those with peritonitis seventy-five 
per cent. But even the complication with general peritonitis 



DISEASES OF THE DIGESTIVE ORGANS. 405 

need not be despaired of. E. Abbe (Med. News, May 29, 1897) 
concludes from a large array of such cases, his own included, 
that "the earlier the operation the better the prognosis;" but 
"there still remains a chance for life if the period elapsing be 
not more than two and one-half days/' 

In many acute cases with violent symptoms a timely opera- 
tion alone will save the patient. To establish the indications 
for surgical interference in these cases is, however, rather diffi- 
cult. Pulse, temperature, and local pain (with or without 
pressure) and swelling require close watching. If the pulse 
goes up to 120-1-10 and stays there, if after five or six days there 
is no improvement in the general symptoms, in the fever and 
swelling (or only either of them), I consider the indication for 
operation very urgent. A general rule, however, cannot be 
made. 

The indications for the time in which the operation is to be 
performed are not easily found in many cases. Indeed, the 
opinions still vary with the very best authors and surgeons — a 
great many of whom, in all countries, have given the very 
closest attention and the very best thought to the subject — as 
to the best time in which the operation ought to be resorted to. 
Some recommend and practise the operation as soon as perfora- 
tion of the vermiform process has taken place, some favor pro- 
crastination until the beginning of the second week. Besides, 
there are those who object to any operation when universal 
peritonitis has set in, and those who perform laparotomy in the 
very same class of cases. In a number of instances the time of 
the operation depends on the condition of the patient; imme- 
diately after the perforation of the gut collapse is sometimes so 
great as to render the operation absolutely inadvisable. In 
these ice, opium, and stimulants are required to bridge over the 
imminent danger until the operation can be safely performed. 
I have seen such cases in which it was considered positively 
fatal at first, and proved successful a week afterwards. There 
is no class of cases in which the responsibility of the medical 



406 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

man is greater, and full knowledge and keen judgment are 
more urgently demanded. Not every case terminates in sup- 
puration. In some there is a great deal of inflammatory exu- 
dation. In them the protracted use of the iodide of potassium 
or sodium, lanolin ointments of the same, and occasional vesi- 
catories will render good service. I have known many who had 
repeated attacks extending over years, and finally got practically 
well, not having anything to complain of for long periods. 

Still, there remain the results of the inflammation, cicatriza- 
tion, shrinking, adhesions, and the constant danger of a relapse. 
If those cicatrices and the appendix were removed, how much 
safer that would be. The responsibility to advise an operation 
for the purpose of removing the appendix of those who have 
suffered from repeated attacks is great, that of not advising 
it is still greater. Of thirteen children of Broca's operated for 
that purpose after recovery from one of the attacks, — that is, 
elective treatment between attacks, — all got well. Of seventy- 
two operations during the attacks, however, thirty-five per cent, 
died; of five children whose appendix was removed during the 
operation for an acute attack, three died. 

The indication for the operation in acute cases, and the selec- 
tion of the time for its performance, are, perhaps, apt to be in- 
fluenced by the observation — in New York City — of two facts: 
first, no matter what its unknown cause or causes may be, ap- 
pendicitis is becoming more and more frequent; secondly, it 
is becoming more septic. In emergency cases, in the hands 
of the most skilled operators, many cases have died of sepsis 
soon after the operation, though it was not much delayed. 
That observation is liable to encourage early interference. 

After recovery, purgatives must not be given for a long time; 
but, as a matter of precaution, warm enemata should be admin- 
istered every day. 

5. Paratyphlitis. 

That name refers to local inflammation, exudation, and sup- 
puration which have nothing to do with the vermiform process, 



DISEASES OF THE DIGESTIVE ORGANS. 407 

but with the copious connective tissue between the bones of the 
pelvis and the colon, which at that place is not covered by 
peritoneum. 

Such abscesses are sometimes the result of trauma; not infre- 
quently of pelvic abscess; of inflammation of the psoas; of caries 
of the vertebrae; sometimes no cause can be found, even while 
or after it terminated in recovery. They will develop rapidly 
and some become very large. Sometimes pints or quarts of pus 
will either be discharged spontaneously or be removed by inci- 
sion. Still, suppuration will not always result from this in- 
flammatory process in the connective tissue, but organizing 
exudation and thickening only. When this happens, the treat- 
ment consists in the internal use of the iodides, and the appli- 
cations of ointments of iodoform or iodide and lanolin, or of 
iodoform collodion (1 : 8-10) several times daily; cold-water 
applications which are kept up until they become warmed; or 
sometimes warm poultices, particularly in the cases of very 
anaemic children. 

6. Intussusception. 

Twenty-five per cent, of all the cases of invagination or in- 
tussusception of the bowels occur in the first half-year of life 
(two-thirds of them between the fourth and sixth month), and 
fifty-three before the end of the first year.* Thus, a knowledge 
both of the condition and the means to remedy it are essential 
to the family physician. The only successful treatment con- 
sists in the reposition of the intestine. When it has been ac- 
complished the relief to all the symptoms is immediate. The 
anxious expression, pallor, and collapse improve instantly, the 
little patient goes to sleep, and soon takes food. In the com- 
mencement of my practice, when an invagination extended 
down to the rectum I employed large sounds for the purpose 
of reducing the invaginated mass, but I have almost invariably 

* See my "Intestinal Diseases," p. 242. 



408 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

found the case to be worse afterwards, because the sound will 
crowd the parts upon each other. I also used to blow air into 
the intestine through a long tube by means of bellows; and in 
order to make the supply more regular I availed myself, thirty 
or forty years ago, of an apparatus for the production of car- 
bonic-acid gas. After that time, when the siphons with car- 
bonic acid and mineral waters were invented, I used them for 
the purpose of filling the intestine more or less slowly with 
both gas and water. All these measures have proved successful 
in occasional cases. What has rendered me better service, how- 
ever, is the following simple plan: The baby is turned on its 
belly, the hips are raised, the abdomen gently supported by a 
soft pillow. The mouth and nose, being the lowest part of the 
body, must be protected. The baby is then anaesthetized with 
chloroform, and warm water is poured into the rectum with but 
little pressure, not from a height of "fourteen feet." This is 
important, for the intestine is no iron pipe subject to the laws 
of hydrostatics only. The injection is frequently intermitted, 
while the anus is closed by the finger. At the same time the 
abdomen, in the direction from below upward, is gently 
kneaded and its contents moved about. 

In not a few cases have I seen immediate result from this 
treatment in the course of the last twenty or thirty years. 
When reduction has been completed, the baby must be kept 
absolutely quiet, take opium, now and then a rectal injection 
of chloral in solution, and wear an abdominal bandage just 
tight enough to steady the bowels. Eelapses are not at all un- 
common; probably it was a case of frequently relapsing intus- 
susception in which Knaggs operated after forty-four days 
(London Lancet, April 24, 1891). 

In adults, Kussmaul reports favorable results from washing 
out the stomach. When the simple measure which I propose 
is unsuccessful, after a number of trials, laparotomy should be 
performed. The successful cases of laparotomy are not very 
numerous, but sufficiently so to justify the operation as the 



DISEASES OF THE DIGESTIVE ORGANS. 409 

only means that promises a favorable result in irreducible cases. 
The late Henry B. Sands was one of the first who saved a baby 
of six months by this operation; at present the number of re* 
ported (and not reported) cases, both successful and unsuccess- 
ful, is very great. The latter should not count to the same 
degree as the former. All those who are saved by the opera- 
tion would have died without it. Pitts (London Lancet, June 
12, 189?) saved six out of seven consecutive operations. It 
is necessary to operate in time, and not delay too long; for 
at the best, laparotomy, in these cases, has its serious diffi- 
culties, and prolonged abdominal operations are not borne by 
infants. 

At an early period all the tissues involved are hyperaemic 
and soft, with a tendency towards gangrene. In a child of 
eight weeks, on whom I operated, it took me ten minutes to 
separate the parts from each other, although I had the invagi- 
nation, measuring six or seven inches, outside of the abdominal 
cavity. This delay was due to the softness of the tissues, the 
close impaction of the three layers, and the presence of a large 
amount of mesentery in the mass. Besides, the field of opera- 
tion is very small and the difficulty of returning the intestine 
into the abdominal cavity very great indeed. 

7. Helminthes. 

The medicines available for dislodging intestinal worms are 
all strongly irritant. They must not be given unless the diag- 
nosis has been made positive. It is better that the diagnosis 
of a gastritis, enteritis, or meningitis, when present, should be 
made by the medical man than that the child should be pun- 
ished for his carelessness. Before taking anything to expel 
tcenia, a child ought to be in fair general condition. Moreover, 
its own taenia, the mediocanellata, is the most difficult to dis- 
lodge. The best time is when proglottides are seen in the move- 
ments. Moderate abstinence for days, at least for one day, and 
a purgative (castor oil), ought to precede the administration of 



410 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

drugs. The parasite must be expelled; for though the symp- 
toms may not be urgent, some day there will come either local 
or reflex disorders, possibly attended with danger. 

Spontaneous emigration will be noticed occasionally, but it 
is rare and should not be waited for. After the successful ter- 
mination of the cure the intestine should be allowed rest. The 
plainest diet, such as milk, strained farinacea, and peptones, is 
indicated for days. 

I have administered a great deal of kamala, sometimes ten 
to fifteen grammes (a quarter to one-half of an ounce), during 
one hour, early in the morning; the breakfast (milk) to be post- 
poned for two hours. The effect was not uniform, and often 
negative. It was improved by giving a dose of twenty-five cen- 
tigrammes to one-half gramme (four to eight grains) four or 
five times daily, for ten days or more, previous to the larger 
dose. A few hours after the larger dose castor oil ought to be 
given. 

Kousso, four to fifteen grammes within two hours, after the 
required preparation, to a child of from two to ten years. 

Ethereal extract of filix mas has proved most successful in 
my hands. A small child may take one gramme (fifteen grains) 
in an aromatic mixture, or in one or more capsules, within one 
early morning hour. Pour grammes are tolerated and required 
by a child of seven or eight years. The oleoresina aspidii of the 
Pharmacopoeia seems to act differently when purchased at dif- 
ferent places. As the whole procedure of expelling a taenia is 
no trifle, it is worth while to be very careful in the preparation 
selected. 

Pelletierin tannate is given in doses of one or three deci- 
grammes (grs. 1J-5). I have but little experience with it. It 
is obtained from cortex punicae granatum, which was (and is 
still) given as a decoction, but is too disagreeable and some- 
times dangerous a mess for a child or infant. 

For the removal of ascaris some general preliminary treat- 
ment like the above should precede medication; at least, the 



DISEASES OF THE DIGESTIVE ORGANS. 411 

bowels ought to be moved gently. The powdered semina cynae 
(Santonicae), or flores cynaa, one gramme or more, mixed with a 
syrup, and followed by castor oil, will work well, but is very un- 
palatable. Santonin, which is obtained from it, works as well 
and more pleasantly; from one to six centigrammes (gr. J-J-l) 
several times a day, with a purgative such as magnesia, calomel, 
or jalap. The latter addition is desirable, inasmuch as now and 
then poisonous symptoms may appear. Older children will 
complain of "xanthopsia," yellow vision. Urine and conjunc- 
tiva? are yellow, sometimes. 

As oxyuris vermicularis is frequently found in the rectum, 
or its neighborhood, the internal administration of drugs will 
not relieve the local itching. Vaginal catarrh, resulting from 
the immigration of the worm, must be treated locally. The 
worm is removed by a small piece of blue ointment introduced 
into the rectum, or rectal injections of vinegar and water 
(1 : 3-4), of corrosive sublimate (1 : 1500-6000), or of decoc- 
tions of onions or garlic. It is difficult to dislodge, as it also 
inhabits the colon and even the small intestine. 

Anchylostoma duodenale has attracted a great deal of atten- 
tion of late, and may become of more practical importance to 
us when the blessing of immigration from the parts where 
the worm is indigenous will go on as hitherto. 

The male is from six to ten, the female from ten to eighteen, 
millimetres in length (^-J inch). The mouth is bell-shaped; 
there are two dental prominences above and four below. Par- 
ticularly the female is thus characteristically endowed, so that 
it sucks and bites at the same time. Eggs, smaller than those 
of ascaris, are found in the fasces of the patient. The parasite 
was found in large numbers among the Italian workmen of the 
St. Gothard tunnel, the tile laborers of the Ehenish provinces, 
and the Hungarian miners and their children. The cause of 
its presence is looked for in the muddy water they drink, which 
is filled with the ova, and the clay they work in, which contains 
the larvaa. The general symptoms are very severe and dan- 



412 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

gerous, — debility, pallor, utter exhaustion like that of per- 
nicious anaemia, and relative diminution of red blood-cells. 
This "Egyptian chlorosis" was explained by Griesinger by the 
presence of anchylostoma, as early as 1854. Besides, there is 
pain in the epigastrium, constipation, mucous and bloody dis- 
charges, sometimes real hemorrhages and dyspnoea. 

Anchylostoma duodenale requires santonin, thymol (adults 
took from two to ten grammes daily), and principally extract of 
filix mas. It would not enter the digestive organs if the water 
were boiled and filtered before drinking. 

8. Umbilical Hernia* 

It is of very frequent occurrence, but seldom attended with 
danger. Incarceration takes place very rarely; still, Treves 
and others have reported successful operations for such acci- 
dents. As there is a predisposition to the development of this 
variety of hernia, so there is a tendency towards spontaneous 
recovery. The round umbilical aperture will normally change 
after a number of months, or even a year, into a narrow fissure, 
more fat will develop, the muscles will become stronger, and 
then the intestine will be retained within the abdominal cavity. 
To accomplish this still more certainly, it is desirable to retain 
the contents of the hernial sac inside the abdomen. For this 
purpose trusses are very unavailing. Strips of adhesive plaster 
will serve very much better, but in most cases they are objec- 
tionable because they irritate the sensitive skin of the baby. 
An adhesive plaster ("Dieterich's"), containing from ten to 
twenty per cent, of zinc, lately introduced, does not irritate and 
answers the purpose. 

Whatever application is made to the hernia directly must 
be larger than the aperture. It should not be too hard. Linen 
compresses, and those of woven lint, plates of cork covered with 
linen or lint, may be applied and held in position by means of 
a bandage. Knitted bandages will suit better than the ordinary 
bandage of linen, cotton, or flannel. 



DISEASES OF THE DIGESTIVE OEGA^S. 413 

9. Inguinal Hernia. 

In the newly-born or the very young it is apt to disappear 
spontaneously; when, however, it depends on or is complicated 
with phimosis, circumcision should be performed to prevent the 
straining caused by it. When the short aud straight inguinal 
canal, in the course of a few years, becomes longer and more 
oblique and the amount of fat goes on increasing, the rupture 
may disappear; but all these predisposing factors never suc- 
ceeded in effecting a cure by themselves. This was accom- 
plished only when the hernia was retained inside the abdominal 
cavity completely and constantly, by means of a truss, which 
must be worn for years. It must not be removed except when 
the baby is sleeping quietly. Trusses are uncomfortable in the 
beginning, and give rise to cutaneous irritation, particularly 
under the influence of urine. So much the more is it necessary 
to keep the truss clean, and always to select one which fits ex- 
actly without exerting too much pressure. If these mechanical 
means did not effect a cure after a few years, the radical opera- 
tion (Bassini, Kocher, or a new procedure devised by Geo. E. 
Fowler, which consists in intraperitoneal displacement of the 
spermatic cord and obliteration of the internal ring and in- 
guinal canal (N. Y. Polyclinic, July 15, 1897), will save the 
patient much discomfort, and removes the danger of a possible 
strangulation. A similar operation is recommended by Xelaton 
and Ombreville (Lyon Med., August 1, 1897). Lannelongue's 
method of injecting chloride of zinc solutions into the tissue 
should be recommended as little as the same method applied to 
tuberculous joints, or to spondylitis. 

Hernia is easily reduced into the abdominal cavity, in most 
instances, by gentle pressure while the legs are raised, some- 
times best in a warm bath or under the influence of an anaes- 
thetic. But there are on record quite a number of cases in 
which incarceration and strangulation required operative inter- 
ference. The operation should not be delayed after reduction, 



414 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tried under the influence of an anassthetic, proved impossible. 
The mortality after the operation does not seem to be larger in 
children or infants than in adults. An instance of a successful 
operation on a case of strangulated femoral hernia, which oc- 
curred in a girl of eleven years, has been reported by St. Ger- 
main, also by Dowd {Arch. Ped., May, 1897), and others. Eees 
succeeded in reducing an inguinal hernia by aspirating from 
the intestine a quantity of turbid liquid. An exceptional case 
of the kind, however, must not be recommended for general 
adoption. If strangulation is old, taxis should not be at- 
tempted at all. 

10. Catarrh of the Rectum. 
It behaves very often like a merely local disease. Indeed, 
it may occur as the result of a local irritation of the anus 
(scratching, sitting on muddy stoops), of oxyuris, foreign bodies, 
or of hardened fasces. The immigration of bacteria through 
the anus was discussed above (p. 396). In all these cases 
the treatment has to be directed to the cause, which must be 
removed. Warm injections of water, flaxseed tea, starch decoc- 
tion (with a little opium in tenesmus) are ample. Real proc- 
titis, leading to ulceration (other than dysenteric) or fibrous 
hyperplasia, will not result frequently. But it may occur, the 
infiltration may become copious and lead to an invasion of 
the surrounding cellular tissue. This periproctitis gives rise to 
abscesses, and often to fistula, either external or internal, com- 
plete or incomplete. These, as well as the periproctitic ab- 
scesses, due to pyaemia, sepsis, or the severe form of typhoid 
fever, require early incision and large and careful antiseptic 
after-treatment. 

11. Prolapse of the Anus and Rectum. 
It is the consequence of catarrhal and inflammatory irrita- 
tion and softening. It may follow chronic catarrh and dysen- 
tery. It is produced by debility of the sphincter, which is often 
congenital, or sometimes the result of neighboring diseases; 



DISEASES OF THE DIGESTIVE OBGANS. 415 

also due to drastic purgatives, or to constipation with the inci- 
dental straining. Such straining, resulting in prolapsus, is also 
produced by the presence of polypus or worms in the rectum, by 
stone and catarrh of the bladder, and phimosis. A predisposi- 
tion arises from the peculiar shape of the rectum in the young. 
It is straighter, inasmuch as the sacrum is not so concave as it 
is in the adult. 

The temporary reduction of the prolapse is readily accom- 
plished, particularly in those many cases in which the sphincter 
is feeble, but the intestine will come down again. Atten- 
tion must be paid to defecation. The children should not 
be allowed to strain. Thus the chamber, if any be used, should 
be placed in such a position, and raised to such an extent, that 
the feet cannot touch the floor, or the child must not be per- 
mitted to sit up during defecation.* 

Many applications have been devised to retain the rectum 
inside. Adhesive plaster has been used «s best it could, and a 
number of instruments have been invented for the purpose 
of retaining the rectum in position, while leaving an opening 
for the passage of the fasces. They have been made of hard 
rubber, lead, and other materials. Some have used a tampon, 
and others a compress to hold the nates together; but a tampon 
will certainly dilate the paralyzed sphincter more than it was 
before. Curling confines his efforts to compressing the nates. 

* Hippocrates makes the following remark on this subject: "In chil- 
dren suffering from stone, and protracted genuine dysentery, the 
rectum is apt to protrude. It should be pressed in with a soft sponge, 
and touched with a snail. Then the patient should have his hands 
tied, and be suspended a short time, and thus the rectum will slip in. 
If it comes down again, a band should be placed around the loins; a 
bandage must be attached to this, and the rectum, after being moist- 
ened with a decoction of lotos, be replaced with a soft sponge. Also, 
the intestine must be washed with this decoction and the bandage 
carried up between the legs to the umbilicus. During defecation the 
baby must sit with extended legs upon the feet of the mother, its body 
leaning against her knees." 



416 THERAPEUTICS OE INFANCY AND CHILDHOOD. 

The main attention should be paid to the treatment of con- 
stipation or diarrhoea, of the local catarrh, the rectal worms, 
the presence of polypi, and to the presence of stone in the 
bladder and phimosis, and all the causes of straining and pro- 
lapse which have been enumerated above. 

But there are direct indications. Astringents have been used 
locally in the form of injections; principally alum and tannin, 
in solutions of one or two per cent. Ice has been applied 
locally, and injections of from half an ounce to an ounce of ice- 
water may be used with advantage, three or four times a day. 

One enema must be given daily for the purpose of empty- 
ing the bowel and thus avoiding the possible straining. 

In most cases there is considerable swelling, sometimes real 
hypertrophy of the mucous membrane and of all the tissues. 
Swelling and hypertrophy must be reduced. A part of the hy- 
pertrophied tissues has been excised. Caustics have been used, 
for instance nitrate of silver. It should be carefully neu- 
tralized immediately after the application by chloride of sodium 
in solution. Concentrated nitric acid has been employed for 
the purpose of destroying some of the superfluous tissue. The 
best remedy, however, for this purpose is the actual cautery. 
It should be applied either in long welts or strips, or at half a 
dozen or a dozen points. It matters not whether the galvano- 
cautery, or Paquelin's thermo-cautery, or the common actual 
cautery is selected. 

For the purpose of strengthening the sphincter, I have used 
frequently, for dozens of years, an ointment consisting of ex- 
tract of nux vomica, one part, in ten or fifteen parts of fat, to 
be applied to the lower part of the rectum from three to five 
times a day, or every time the bowel protrudes. The internal 
administration of strychnine is of very little avail; but that of 
ergot is serviceable. The subcutaneous injection of strychnine 
(sulphate one-sixtieth to one-thirtieth grain dissolved in water, 
once daily) in the neighborhood of the sphincter will be bene- 
ficial, particularly when supported by the action of the inter- 



DISEASES OF THE DIGESTIVE ORGANS. 417 

rupted electric current, which may be applied for a few minutes 
once or twice every day. Rational treatment is required for 
the constitutional causes of debility and emaciation (rhachitis, 
tuberculosis). 

12. Fissure of the Anus. 

It is by no means rare in infants and children, particularly 
in the latter. It gives rise to symptoms similar to those en- 
countered in adults: severe pain during defecation, tenesmus, 
dysuria. Many cases of alleged flatulency and colic, and ex- 
cruciating screaming spells, are due to fissure. The more 
severe form follows a direct injury by foreign bodies, hard 
fasces, etc.; a mild form is due to slight erosions and ulcera- 
tions, the rhagades of congenital or acquired syphilis, or the 
sores made by erythema, eczema, or herpes, and by vulvo- 
vaginitis. The mildest form is that which is found on a very 
loose and dilatable anus. This yields readily to a mild treat- 
ment of the sore with a solution of nitrate of silver. Cases 
depending on syphilis require both a general and local treat- 
ment; vaginal catarrh must be stopped, and eczema healed. 

The treatment of the severe form has consisted in the relief 
of occasional diarrhoea, and that of the more frequent consti- 
pation by enemata and mild purgatives, in the application of 
astringents, such as lead, copper, zinc, or alum; or of caustics, 
such as nitrate of silver (Esmarch) or of nitric acid. This 
treatment is painful and tedious. Boyer advised incision 
through the whole of the sphincters. The open wound, how- 
ever, may bleed and give rise to ulceration, or sepsis. The 
proper treatment consists in dilatation of the sphincters. Jos- 
seline directs it to be gradual, thereby protracting uncertainty 
and pain. The best and speediest method, however, is forcible 
and instantaneous dilatation, without or with anaesthesia. The 
operation takes so little time that it is hardly required except 
in very puny or convulsive infants or children. The introduc- 
tion of two fingers of the same hand is rarely sufficient; three 
or four do better, or the thumbs of both hands. The easiest 

27 



418 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

way is to use the two index-fingers for pulling; a sufficient 
dilatation is recognized by the distinct sensation that the mus- 
cular fibres have given way. The external wound is trifling 
and but superficial. 

In the rare cases of fissure and polypus combined the treat- 
ment has to be directed to both. 

13. Polypus of the Rectum. 

They are tumors of the size of a pea up to that of a cherry or 
hazel-nut, or more. They are single or numerous, quite soft, 
or more frequently of greater consistency, composed mostly of 
cells or cellular tissue, quite vascular, and contain often a 
harder adenomatous nucleus and a Lieberkiihn gland embedded 
in them. They are either pedunculated or sessile, on a broad 
base. They are sometimes found between the two sphincters, 
mostly above and near the inner sphincter; not infrequently, 
however, all over the middle portion of the rectum, and some- 
times quite near the "third sphincter." 

Among the symptoms we occasionally meet with abnormal 
defecation (constipation, diarrhoea, or both in alternation), 
sometimes with enteralgia or tenesmus, and frequently a dis- 
charge of mucus or blood. Tenesmus is found about polypi 
when seated near the internal sphincter, or between the two 
sphincters. Blood is seldom mixed with mucus, mostly quite 
clear, from half a teaspoonful to a teaspoonful, sometimes 
more, so that the constant repetition of these small hemor- 
rhages is sufficient to result in anaemia, but also to establish 
the diagnosis. The tumor is often pushed into or through the 
anus during the evacuation of the bowels. 

The treatment consists in the removal of the tumor by 
means of the cold snare, the galvano-caustic snare, by pincers, 
or by the fingers, or by ligature. The latter is easy of applica- 
tion in all cases in which every movement of the bowels suc- 
ceeds in rolling out the growth like a foreign body. In these 
many excursions a polypus with a thin pedicle is often removed 



DISEASES OF THE DIGESTIVE ORGANS. 419 

spontaneously. When that occurs there is hardly a show of 
blood. Indeed, there is seldom much bleeding after removal. 
It is true that some writers report the occurrence of hemor- 
rhages; but in infants and children, with whom varicosities ot 
the blood-vessels are exceedingly rare, I have never seen a 
hemorrhage of any account after breaking the pedicle with my 
finger in the rectum. The latter is very accessible indeed to an 
index-finger of moderate size. 

Sessile polypi do not give rise to urgent symptoms, and are 
not easy to find, sometimes. The astringent injections which 
are to remove them should be mild. Solutions of one per cent, 
of alum, injected several times daily, will be found sufficient, or 
a two-per-cent. ointment, or a suppository. 

G. The Livek. 
The diagnoses of alleged diseases of the liver are more nu- 
merous than its diseases. Primary affections are rare. Enlarge- 
ment is frequently assumed to exist when the size is normal. In 
the foetus and infant the liver is proportionately large, but ap- 
pears still more so because its lower part is not covered by the 
ribs (which in the young are placed more horizontally) as it is 
in the adult. Besides, the tympanitic intestines encroaching 
upon the liver from below and behind, and the rhachitical con- 
traction of the chest-wall, if present, render a much larger sur- 
face of the organ accessible to percussion and palpation. Thus, 
actual and primary enlargement is not a common occurrence. 
Secondary enlargement, however, may depend on constitutional 
— either chronic or acute — disorders, such as alcoholism, syphi- 
lis, leucocythasmia, chronic tuberculosis, suppuration of bones 
or glands, malaria, or typhoid fever. The therapeutics of these 
kinds of enlargement depend, therefore, on the character of the 
different causes. A case of multiple adenoma of the liver in a 
girl of twelve years was published by me in the Trans. Assoc. 
Am. Phys., 1897. Enlargement of the liver should not be diag- 
nosticated when the organ is merely dislodged downward 



420 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

(hepatoptosis). In very rare cases its position may be so 
changed that the diaphragmatic surface looks outward, to the 
right side. 

Another series of enlargements is that which results from 
changes in the circulation. Diaphragmatic pleurisy of the right 
side may constrict the vena cava inferior and thereby lead to 
hypertrophy of the liver, ascites, anasarca of the lower extremi- 
ties, and death. Pneumonia in its acute stage impedes the 
hepatic circulation, temporarily mostly; when it is chronic, the 
consecutive hyperemia may lead up to hypertrophy; the same 
effect may be produced by the persistence of pleural effusions 
on either side. Persistent obstruction of bile-ducts may have 
the same effect. More frequent yet is the secondary hepatic 
enlargement of heart-disease, not so much in the congenital 
form, in which the amount of blood is greatly reduced by the 
low state of general nutrition, as in acquired (mostly rheu- 
matic) endocarditis; also in chronic myocarditis. The number 
of such cases increases with every year of life; indeed, children 
of eight or ten years, with chronic valvular diseases and con- 
secutive enlargement of the liver, are subjects of frequent ob- 
servation. Myocardial alterations are not so frequent. Thus, 
indeed, the treatment of the hepatic disorders is rather that of 
the primary disease than of the secondary hepatic changes. 

Fatty infiltration of the liver is, in the very young, not often 
complicated with much increase in size. For, indeed, to a cer- 
tain extent it is normal. But, in ill nutrition, protracted diar- 
rhoea, chronic pulmonary tuberculosis, and after severe cases of 
diphtheria or scarlatina, an actual fatty degeneration is liable 
to occur, with enlargement of the organ. Sometimes it is 
found combined with interstitial inflammation (cirrhosis), par- 
ticularly in cases of syphilis, rhachitis, tuberculosis, or after 
measles or scarlet fever. All of these facts are here alluded to 
in order to show that the intellectual physician may accomplish 
a great deal by attending to an evil before it is developed. 
Nothing is easier and more luckless than to prescribe iodides, 



DISEASES OF THE DIGESTIVE ORGANS. 421 

calomel, or purgatives for an established local disorder, and 
fold the hands at the sight of an impossibility; nothing more 
efficient and happy than to watch and treat in time rhachitis 
and measles and scarlatina and the whole army of primary ail- 
ments. Obsta principiis. Noiseless prevention counts more 
than the loud officiousness of the recipe fiend after the evil 
has been permitted to advance to maturity. 

Besides the cirrhotic induration of the liver, complicated 
with fatty infiltration, there are rare instances of genuine cases 
of cirrhosis, mostly connected with, or depending on, alcohol- 
ism, syphilis, rhachitis, acute exanthems (measles, scarlatina), 
and tuberculosis. The atrophic form is rare and mostly due to 
syphilis; the hypertrophic, with more or less jaundice and only 
a mild degree of splenic enlargement, is more frequent. Still, 
the records of the journals and transactions exhibit less than 
one hundred cases altogether. Gilbert and Fournier (Sem. 
Med., 1895, p. 248) publish six cases of from five to eleven 
years. There was jaundice in all, the spleens were large, in 
some cases larger than the liver, the last phalanges of fingers 
and toes were enlarged, the nails curved, the ends of femora, 
tibiae, and fibula? enlarged, many joints painful, there was syno- 
vial effusion in the knees. All the children were undersized 
and puny. Ascites is not so frequent in the young as it is in the 
adult; it is more often observed as the result of chronic peri- 
tonitis than of cirrhosis, and of portal obstruction of any kind. 
The energetic suppression of the alcoholic habit (more fre- 
quently found in children and adolescents than many presume) 
and the treatment of syphilis (not always hereditary) may result 
in recovery. Ascites gets well sometimes after a single paracen- 
tesis. Mercury and iodides are very effective, not only in syphi- 
litic cases. In every sort of cases, and in every age, I have 
succeeded in relieving cirrhosis, and sometimes permanently, by 
alternating, by the week or fortnight, the administration of 
iodides (potassium or sodium) and mercury (bichloride or the 
green iodide, and sometimes calomel). 



422 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

The therapeutics of congestion of the liver is that of its 
causes, the lungs and heart, phosphorus-poisoning, infectious 
fevers, or very high temperatures. While nothing is more 
preposterous than the abuse of antipyretics in the presence of 
moderate temperatures, nothing is indeed more reprehensible 
than to allow paralysis of blood-vessels and even disintegration 
of tissues to take place from excessive pyrexia. The same is 
true of hepatic inflammation and suppuration. In our country 
the former, when general, is mostly traumatic, the latter the 
result of pyaemia, umbilical phlebitis, dysentery, perityphlitis, 
and pleuritis, besides an occasional case produced by pylephle- 
bitis, or the immigration of an ascaris, or a contusion. Many 
a case of abscess need not have occurred if the dysenteric rec- 
tum had been disinfected by frequent enemata, a perityphlitic 
or pleural abscess been incised in time, and the umbilical phle- 
bitis prevented by keeping the cord aseptic. Multiple abscesses 
will always terminate fatally; a single abscess may get well by 
either aspiration or incision and drainage. Of the two I prefer 
the latter, though, indeed, I have seen a successful result from 
a single aspiration followed by antiseptic irrigation. 

Acute yellow atrophy has been observed in infants of from 
one month to fourteen years. Greves (Liver p. Med. Sur. Journ., 
July, 1884) collected seventeen cases; I have seen but two, with 
pain, vomiting, jaundice, nephritis, fever, and early brain symp- 
toms. They all die, mostly within a week. 

The treatment of jaundice depends on its causes. The dan- 
gerous form met with in the septic new-born might have been 
prevented, but cannot be cured. That which results from 
syphilitic stricture of the bile-ducts may recover, even after 
months, through a thorough mercurial treatment; complete 
obliteration of the bile-ducts leaves no hope, except in those 
cases which can be proved to be inflammatory. In them per- 
sistent alternation of mercury and iodides may relieve, or re- 
store health. With mercury alone, aided by but little iodide 
of potassium in the rectum, a child of ten years with large and 



DISEASES OF THE DIGESTIVE ORGANS. 423 

hard liver (probably fatty, previously) got well of icterus which, 
lasted five months and was complicated with secondary ne- 
phritis. The mild form depending on the sudden postnatal 
change in the hepatic circulation corrects itself; that which 
follows a gastric and duodenal catarrh in the newly-born, the 
infant (rarely), or the child, will get well with proper diet and 
medicines, which have to be adapted both to individuality and 
age. As a rule, the amount of food ought to be diminished, but 
little meat (chicken) permitted, and milk and farinaceous foods 
preferred. Alkaline waters (Seltzer, Vichy, Waukesha, Poland), 
bicarbonate or phosphate of sodium, bismuth, hydrochloric 
acid, resorcin, calomel, will be found appropriate in a great 
many cases; in others, copious cool enemata or tinctura rhe'i 
aquosa. Jaundice attributed to the influence of foods, locali- 
ties, miasms, and atmospheric influences has been observed to 
occur epidemically. Such cases require, besides the treatment 
outlined above, rest in bed, warm bathing, and diaphoretics. 
H. Pletzer (7th Ann. Rep. Health Dep., Bremen) reports an 
extensive epidemic, not contagious, after revaccination. The 
glycerin lymph (humanized) which was employed, was all ob- 
tained through different agents, from Eastern Prussia. Jaun- 
dice from gall-stones, though it has been observed in the very 
young, even in the newly-born, is excessively rare. The rules 
both for dietetic and medicinal treatment of biliary calculi 
must be the same in all periods of life. Strictly nitrogenous 
food should be avoided or taken in small quantities only, and 
milk and fruit (oranges, grapes) and fresh vegetables permitted. 
Of all the medicinal agents known to me, the sulphate and the 
salicylate of sodium, administered for months in succession, 
have answered best as preventives, to guard against a repetition 
of the attacks. 

Baccelli's method of operation in echinococcus of the liver 
consists in aspirating thirty cubic centimetres (one ounce) of 
the liquid through a thin aseptic trocar and injecting twenty 
cubic centimetres of a one-per-mille solution of corrosive sub- 



424 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

limate. The puncture is then covered with gauze and adhesive 
plaster. In a few days the sac begins to be smaller, and finally 
contracts. I. von Bokay publishes three successful cases (Arch. 
f. Kindh, 1897, p. 310). 

H. The Spleen. 
Diseases of the spleen are rarely of a primary character; but 
most cases of pseudoplasm are congenital, and not amenable to 
any medicinal treatment, except sarcoma which cannot be 
cured, but favorably influenced by arsenic and by the toxin of 
the erysipelas coccus and the bacillus prodigiosus (Coley). It is 
not so rare as it is reputed to be. I am certain I see a case an- 
nually. The majority of changes occurring in the spleen are 
connected with, or dependent on, constitutional ailments, and 
result mostly in enlargement of the organ. Malaria, leucocy- 
thaemia and pseudo-leucocythsemia (Hodgkin's disease), and 
amyloid degeneration have their own indications. Ehachitis 
and syphilis are liable to produce induration depending on 
hyperplasia of the connective tissue. Tuberculosis of the 
spleen is a frequent complication, sometimes the first place of 
deposit in the very young, of general tubercular infection. The 
deposits are sometimes of microscopical size only. The differen- 
tiation between tubercular deposits (transparent in very acute 
cases only, otherwise slightly yellowish, sometimes caseous, of 
unequal size and irregular distribution) and the follicles of the 
spleen is not always easy. Heart-disease may lead to embolism 
and abscesses (the latter forming also a part of general pyasmia), 
typhoid fever to softening and enlargement. This condition 
expands the peritoneal covering and causes perisplenitis, 
though it be not quite distinctly accessible to diagnosis. For 
indeed the younger the infant the less is percussion — being 
hampered by the shortness of the chest and the frequent oc- 
currence of tympanites — able to reveal the exact size of the 
spleen. Unless it can be felt below the margin of the ribs, it 
should not be assumed to be enlarged. There are even cases in 



DISEASES OF THE DIGESTIVE ORGANS. 425 

which it can be so felt, and still there is no enlargement, for in 
rare instances the spleen is found descended or floating. 

The therapeutics of the constitutional disorders above al- 
luded to has been discussed in previous papers. Quinine, ergot, 
and arsenic have been shown to be efficient in some and abso- 
lutely inert in others. The combination of quinine and ergot, 
with or without iodides, is probably among the most powerful 
remedies in chronic cases. Acute instances of swelling and 
inflammation require ice energetically applied, purgatives, and 
large doses of ergot; the presence of pus demands incision and 
drainage. To ascertain that condition exploring punctures, 
carefully executed, can be made with safety. To what extent 
extirpation of the organ can be rendered serviceable in chronic 
cases remains for the future to demonstrate. Many of them 
that are dependent upon disorder of circulation or nutrition 
are more amenable to a preventive than to a curative treatment. 

I. Peritonitis. 
Whether acute, subacute, or chronic, it is a frequent occur- 
rence at any age, and quite common in the young. The several 
forms will interchange and combine or alternate with each 
other; the chronic variety may remain dormant through an in- 
definite period, and suddenly break out with full force. All the 
forms of septic and infectious diseases give rise to it, from the 
sepsis of the newly-born to scarlatina, erysipelas, variola, dys- 
entery, and typhoid fever (much more frequently without than 
with perforation). Trauma and perforation from any source, 
straining and contusion, indigestion, diarrhoea, and constipa- 
tion (less frequently in the young than in the adult) will lead 
up to it. Inflammatory processes in the neighborhood, such as 
pleuritis, or simply local irritation, from incipient hernia or re- 
tained testicle, are among the frequent causes. Perhaps the 
most frequent origin is that from a previous attack which oc- 
curred at a period ever so distant. After all that has been said 
in these brief lines, it is easy to see to what extent preventive 



426 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

treatment may prove effective. The watching and mitigation 
of infectious disease with a typical course, the speedy disinfec- 
tion of the intestines in typhoid fever and dysentery, the pre- 
vention or cure of chronic constipation or diarrhoea, the proper 
attendance on appendicitis and pleuritis, the application of a 
truss and alleviation of the difficulties of a strangulated testicle, 
are just so many safeguards against attacks of peritonitis. 

When an acute attack of peritonitis, either local or general, 
has made its appearance, absolute rest is required by both the 
whole body and the affected organs. JSTo unnecessary exertion, 
no motion of the body, no sitting up to evacuate either bladder 
or bowels, no straining are permissible, no food other than 
liquid, — that is, milk and such f arinacea as contain least starch, 
— viz., ground barley or oatmeal, preferably the former. Meat 
requires more pepsin and hydrochloric acid than a stomach at a 
temperature of 104° or 106° is competent to furnish, and the 
system has no worse enemy than half-completed or not ab- 
sorbed peptones. Peristalsis must be stopped, for any dis- 
turbance of the consolidation of beginning adhesion is revenged 
by the tearing of newly-formed blood-vessels, the occurrence of 
hemorrhages, and the increase of danger. Opiates should be 
given by the mouth, rectum, or subcutaneously, or by com- 
bined methods, in doses sufficiently large not only to benumb 
pain or to procure an occasional sleep, but to obtain a condition 
of constant drowsiness, even sopor, and an effect on the pulse. 
When there is much vomiting, food ought to be withheld for 
half a day or a day. There are cases in which even ice pills fur- 
nish a new source of gastric irritation; still more frequent is 
the contraindication to carbonic acid gas, which, it is true, 
gives great relief in some cases either in an alkaline water or in 
champagne. In the later stages of the disease, when the neces- 
sity of feeding becomes urgent, vomiting may often be avoided 
by giving, either subcutaneously or on the tongue, undiluted, 
one or a few drops of Magendie's solution five minutes before 
the partaking of food. In the first days of acute peritonitis 



DISEASES OF THE DIGESTIVE OEGANS. 427 

water is a greater necessity than food. When it cannot be in- 
troduced into the stomach, an ounce or two may be thrown into 
the rectum every hour or two hours without annoying it, and 
without inducing peristalsis of the intestinal tract. 

Ice-bags or, if they be too heavy, the ice-water coil, or iced 
cloths are applied to the abdomen to advantage; the former 
mainly when the inflammation is still local. When they are ob- 
jected to, water of the usual temperature may be employed first, 
and the latter reduced gradually. Cold must not be employed 
too long in very young or anaemic children; in these, indeed, 
warm applications are tolerated best. As long as an acute peri- 
tonitis is still local (pericystitis, perihepatitis), leeches may be 
expected to do good. No purgatives must be given; in chil- 
dren peritonitis caused by constipation is exceedingly rare, and 
the recommendations of magnesium sulphate, recommended by 
some gynaecologists in puerperal and other forms of peritonitis 
— though they may be considered justifiable in the adult — do 
not hold good for the infant or child. If it be desirable to re- 
lieve the intestinal tract to some extent, the incipient state of 
peritonitis may permit of a tepid enema gently administered, 
with or without the addition of a teaspoonful or half a table- 
spoonful of oil of turpentine added to half a pint or a pint of 
warm water. Rest to the intestinal tract is such an absolute in- 
dication that the locking up of the bowels for a week or ten 
days becomes a frequent necessity. The tympanites of peri- 
tonitis is not the result of constipation, but depends on the 
paralytic condition of the muscular layers of the gut, brought 
about mostly by oedematous effusion into its tissues. But when 
it becomes very annoying, or dangerous through pressure upon 
the diaphragm, some relief may sometimes be obtained by in- 
troducing one or more tubes of India-rubber into the rectum. 
External applications must not be made because of the danger 
attending renewed peristalsis. The question whether puncture 
of the intestine is advisable, with a view of allowing gas to 
escape, cannot be answered for every case. Experience has 



428 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

shown that such punctures accomplished this purpose, but also 
that over-extension of the intestinal wall destroyed its elasticity 
and prevented the puncture from closing immediately. I have 
seen liquid faeces in the abdominal cavity which had escaped 
through the fine apertures made by the needle of the aspirator. 

When the case turns out to be one of suppurative peritonitis, 
the accumulation of pus may be circumscribed (a local abscess) 
or the whole abdominal cavity is affected. In such cases there 
have occurred occasional perforations into and discharges 
through the intestine, ureters, bladder, or umbilicus, but it is 
not windfalls or godsends we have to calculate upon or look for. 
The choice is between an absolutely bad prognosis and the inci- 
sion of the abscess, or laparotomy with proper after-treatment. 
(See p. 405.) As to its performance, I refer to the recent books 
on surgery. If I have anything to suggest it is that the incis- 
sions should not be too small. The latter operation has also 
been recommended as a curative agent in tubercular peritonitis, 
and the number of reported successes is increasing. While we 
know that local tuberculosis is quite liable to heal sponta- 
neously, we are not justified in attributing the recovery of 
laparotomized tubercular peritonitis to that spontaneity alone, 
but should remember that a good empirical observation is of at 
least as great an objective value as a laboratory experiment 
made under different circumstances, or a microscopical draw- 
ing. When tubercular peritonitis is miliary, and complicated 
with general miliary tuberculosis, no operation should be made, 
for the disease will terminate fatally. Simple ascites does not 
contraindicate it, but will often get well without it. In caseous 
tubercular peritonitis, though complicated with chronic pul- 
monary disease, the result of the operation is quite favorable. 
The mere puncture with or without injections is not a proper 
substitute for laparotomy. 

Chronic peritonitis, whether the outcome of an acute attack 
or an independent affection, has its own indications. The ma- 
jority of cases are either traumatic or the results of previous 



DISEASES OF THE DIGESTIVE ORGANS. 429 

diarrhoea, typhoid fever, or tuberculosis. Rest in bed, warm 
bathing, warm poultices, offer great relief. Baths containing 
iodine, such as St. Catherine's, Kreuznach, and the internal 
administration of iodide of potassium or sodium (of iron only 
when there has been no elevation of temperature for some time) 
will contribute to the absorption of part of the exudation, par- 
ticularly when the latter is very massive. An occasional vesi- 
catory will be found opportune. Iodoform may be used as an 
ointment, or be applied in collodion (1 : 8-12), twice daily, for 
a long time. Tincture of iodine is less efficient and more irri- 
tating. Ascites may require paracentesis, but I have seen many 
a case improved by iodides only, in connection with other diu- 
retics. Sparteine sulphate (scoparius) is one of the best, in 
daily doses of, altogether, one to four grains (0.06-0.25). It 
may be combined with the iodide. When the solid exudation is 
obstinate, the blue ointment may be used in addition to the 
iodide; it may be rubbed into the inner aspect of the thighs 
or forearms, particularly the former, twice daily; not, however, 
into the .abdominal wall. Nothing is easier than to transform 
a mild chronic form into an acute peritonitis by friction and 
similar traumatism, and nothing more certain than that the 
modern "massage" craze has multiplied the cases. On the 
other hand, there is no better means of alleviation and preven- 
tion than rest secured to the abdominal organs by the per- 
manent wearing by the patients, or those who ever suffered 
from peritonitis, of a bandage easy enough not to annoy, but 
sufficiently snug to hold in position the jumble of formerly dis- 
eased and still vulnerable intestinal convolutions. 



VIII. 
DISEASES OF THE GENITOURINARY ORGANS. 

1. The Kidneys. 

The preventive treatment of the kidneys ought to begin with 
the first hours of the newly-born. After the second day, and 
frequently through a period of some two or three weeks, the 
urine, usually thin and limpid in the infant, is liable to elimi- 
nate a large amount of uric acid and urates. They are de- 
posited in the pyramids and papillae of the kidneys, also in the 
straight uriniferous tubes, even in the epithelia, as orange- 
colored crystals and an amorphous powder, and are sometimes so 
copious as to accumulate in the pelvis of the organ and. also in 
the bladder. Not infrequently these deposits are combined with 
some organic structure, which is dissolved by acetic acid, or with 
hsematoidin crystals resulting from small extravasations. Quite 
often are the cloths of the baby discolored by them. The pres- 
ence of this "uric acid infarction" is due to the sudden change 
in the circulation of the blood; it causes an unprecedented 
elimination of nitrogenous material which cannot be kept in 
solution and easily removed, because the newly-born is not sup- 
plied with a sufficient amount of water. Its speedy expulsion is 
of great importance, for it acts as a local irritant, and may give 
rise to a slight or a copious renal hemorrhage, to albuminuria 
(which is a frequent occurrence because of the defective con- 
struction of the epithelium of the glomeruli), and even to ne- 
phritis. Besides, its presence in both the kidneys and the blad- 
der is a ready cause of the formation of renal calculi; indeed, 
the vast majority of renal calculi and of the centres of vesical 
calculi consist of uric acid. The consideration of these facts 
430 



DISEASES OF THE GENITO- URINARY ORGAN'S. 431 

conveys at once the conviction of the necessity of supplying the 
newly-born with ample quantities of water. Much suffering 
and illness can thus be prevented.* 

The malformations of the kidneys and their (mostly congeni- 
tal) malignant pseudoplasms furnish but few indications for 
treatment. Abnormal shape and unicity of the kidney (some- 
times amounting to horseshoe kidney), cystic degeneration of 
obstructed uriniferous tubes, carcinoma and sarcoma, are un- 
fortunately not uncommon. Of the latter I collected nearly 
four dozen in my paper on the subject presented to the Eighth 
International Congress, 1884. No treatment can be advised 
but that of removal at a time when the growth of the tumor is 
not yet too large. If no longer possible, the antitoxin (Coley) 
treatment may be tried. Fortunately, the diagnosis can be 
made with satisfactory certainty, and besides, as a rule, there 
is but one kidney affected. Metastatic deposits in the other 
kidney or in other organs take place, if at all, at a late period 
of the development of the pseudoplasm. 

Primary tuberculosis is more frequent in the kidneys than in 
any other part of tHe urinary tract. It is more frequently de- 
scending than ascending, and at first but one kidney is affected, 
begins in the cortex, affects the base of the pyramids, and may 
terminate in abscess. There is enuresis and local pain; blood, 
pus, connective and elastic fibres are found in the urine; but the 
diagnosis is difficult until bacilli are discovered. They are 
scarcely found except by centrifuging. Of fifty-four cases re- 
ported by S. M. Hamill (Internat. Med. Journ., January, 1896) 
seventeen were operated upon; four nephrotomies cured two, 
improved one. One died. Nephrectomy was performed on 
nine; five were cured, one improved, three died. Nephrotomy 
and subsequently nephrectomy were performed on four; one 
died. 

* See my paper on Nephritis in the Newly-Born, N. Y. Med. Journal, 
January 18, 1896. 



432 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Echinococcus and hydronephrosis furnish the usual indica- 
tions. More than one-half of the latter are congenital, and 
therefore unfavorable. The secondary variety is caused by con- 
genital hypertrophy of the bladder, pseudoplasms in the blad- 
der or pelvis, calculi or abnormal valves obstructing a ureter, 
tuberculosis or shrinking, with partial obliteration, of the ure- 
ter, disease of the prostate gland and urethra and its neighbor- 
hood. Thus the prognosis of the causal treatment is very 
doubtful in most cases, and a direct surgical treatment — aspira- 
tion, drainage, and irritant injections — is demanded. A cystic 
tumor weighing three pounds was removed from a child of 
seven months by J. Campbell (Br. Med. Journ., May 15, 1897). 
It was located in front of the left kidney, contained three hun- 
dred grammes of a clear-yellow fluid and a solid mass in which 
a cartilage and a piece of bone were embedded. 

Most cases of floating kidneys in infants and children are 
congenital; in a few older children, of ten and twelve years, 
symptoms attributable to that anomaly originated in a fall or 
jump from a height. Fortunately, it is a rare occurrence; still 
I have met with at least a dozen in the course of more than 
forty years. I never could advise anything better than a snug 
and well-fitting abdominal bandage. I have not seen a case in 
which I felt justified in advising an operation (nephropexy). 

Among the symptoms connected with actual or apparent 
renal disease there are two of such importance as to render a 
special consideration advisable, — viz., hematuria and hemo- 
globinuria. The former is always the result of a rupture of 
blood-vessels which may be occasioned by many causes. Cal- 
culus in a kidney or the bladder, nephritis and cystitis, neo- 
plasms (mainly carcinoma, not often sarcoma), thrombosis of 
the renal vein, or an infectious disease, such as purpura and 
cerebro-spinal meningitis, are among the principal causes of 
hematuria. The angioneurotic form I have not seen in a child. 
The indications furnished in renal hemorrhage by the presence 
of infectious diseases and thrombosis are clear, but the efficacy 



DISEASES OF THE GENITO-URINAEY ORGANS. 433 

of the means considered appropriate is very doubtful. Stone 
in the kidneys requires flushing the organ with alkali according 
to the method to be discussed below. The action of ergot, or of 
hydrastis, either as a fluid or a solid extract, may be tried. If 
the stomach be rebellious the remedy may be administered in 
the rectum, or subcutaneously. Heart stimulants are often in- 
dicated, but digitalis should not be selected, because of its local 
effect on the kidneys. Strophanthus or sulphate of sparteine 
are preferable. Astringents, such as are eliminated through the 
kidneys, lead, tannic and gallic acid, will render good service 
if given in more than the doses of the books. The application 
of ice over the bleeding kidney is superior to any other remedy, 
provided the patient be not too young; for very small infants 
do not bear the persistent use of ice. 

Haemoglobinuria, resulting from dissolution of blood-cells, 
is the occasional result of extensive burns. In the urine, be- 
sides haemoglobin, blood and casts may be found; in autopsies 
mostly blood in the capsule and in the canaliculi, besides 
detritus. 

Nephritis, in the acute, subacute, and chronic forms, is a 
very frequent disease in infancy and childhood. Even in the 
newly-born it is not infrequent (N. Y. Med. Journ., January 18, 
1896). There it is either congestive (from feeble circulation, 
congenital heart-disease, asphyxia, or exposure to low tempera- 
tures), or obstructive (from the physiological rapid decomposi- 
tion of the blood in the newly-born; the formation of haema- 
toidin = bilirubin; from jaundice; from the production of 
methsemoglobin by chlorate of potassium, or by excessive heat ; 
or from the presence of blood in the uriniferous tubes), or irri- 
tative (by uric acid or by haBmatoidin infarctions, by the pres- 
ence of purpuric or other hemorrhages, or of microbes and 
toxins furnished by enteritis or by an infectious disease). As 
nephritis is not always primary, but quite often a secondary 
affection, it is liable to be overlooked until it is too late. When 
this excessive frequency will be generally recognized fatal re- 

28 



434 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

suits will become less, and prevention will be appreciated at its 
full value. The enumeration of the causes of nephritis will 
always be incomplete, but the list of those conditions and dis- 
eases leading to it comprehends the principal ailments of in- 
fancy and childhood. First of all, there are the acute infec- 
tious diseases: scarlatina, diphtheria, measles, rubella, varicella, 
vaccinia even, malaria, typhoid and cerebro-spinal fevers, amyg- 
dalitis ("tonsillitis"), parotitis, and pyaemia. There are consti- 
tutional disorders, such as syphilis, purpura, and diabetes, also 
extensive eczema or impetigo, changes in the superficial cir- 
culation resulting from sudden exposure, sometimes also from 
the persistent influence of a low temperature. The latter 
is not so ominous as the former. A fall into the water, exposure 
to a rainstorm may cause an acute nephritis (interstitial or 
hemorrhagic) which may prove fatal in a few days. The slow 
influence of cold temperatures is better borne, almost as well as 
compulsory overwork of a kidney (for instance, after the other 
has been removed). Stasis and thrombosis, depending on pul- 
monary and cardiac diseases and diarrhoea, have the same result. 
Irritation of the kidneys by medicinal agents also leads up to 
nephritis; thus, for instance, chlorate of potassium, mineral 
acids, salicylic, carbolic, and pyrogallic acids, turpentine, naph- 
thol, styrax, petroleum, tar,* large doses of lead, phosphorus, 
arsenic, mercury, and manganese, — part of which are used for 
internal, part for external medication; finally, irritation of the 
organ by the uric acid infarctus of the newly-born, or by renal 
calculi, which are by no means rare in the very young, gives rise 
to inflammation. Most of these injurious substances exhibit 

* Balsam of Peru has also been charged with occasioning nephritis. 
Brautigam and Nowack, after having made daily examinations of the 
urines of twenty-two patients, though administering internally fifty- 
two and eight-tenths grammes in eleven days, and in another case 
eighty grammes in twenty-four days, found that it has no such detri- 
mental effect, provided it be free of ethereal oils. (Centralb. f. klin. 
Med., No. 7, 1890.) 



DISEASES OF THE GENITOURINARY ORGANS. 435 

their detrimental effect the more the younger the infants; in 
them a single external application of a solution of carbolic acid 
has sufficed to produce nephritis. The large number of causes 
of nephritis, as enumerated above, if heeded, teaches at least 
two lessons: first, that the supine expectancy in the treatment 
of digestive and infectious diseases is very liable to become 
criminal; and, secondly, that the effect of every irritating 
remedy, both internal and external, must be carefully watched. 

When acute nephritis has been fully established, the first 
indication consists in the procuring of relief for the conges- 
tion of the kidneys. The child must be in bed, the skin warm; 
a warm bath will fill the cutaneous blood-vessels and relieve the 
internal circulation; dry cups and hot poultices applied to the 
renal region will have a similar effect. The mucous membrane 
of the intestinal tract should be made to share in the action of 
the skin; therefore, sulphate of magnesium should be adminis- 
tered in doses sufficient to produce three or four daily evacua- 
tions, or calomel in small doses frequently repeated. The 
arterial tension should be reduced by nitrites, particularly when 
there are cerebral symptoms; besides aconite in frequent one- 
quarter-drop doses, small doses of opium frequently given, or 
chloral hydrate, may be tried for the same purpose. Digitalis 
should be avoided in acute cases, but when exhaustion is 
threatening, strophanthus or sparteine sulphate may be admin- 
istered alongside the nitroglycerin. Iodide of potassium acts 
favorably in the same direction; the sulpho-ichthyolate of 
sodium has been recommended for the same purpose by Sen- 
ator, who gives to an adult pills containing from one deci- 
gramme (grs. 1^) to one gramme (grs. 15) daily. 

The greatest care must be bestowed on the diet of the patient. 
"Whatever is irritating must be avoided; for instance, alcohol, 
spice, or iron. The food should be exclusively liquid, and com- 
patible with the vulnerable condition of the kidneys. As the 
first products of the metamorphosis of albuminates are elimi- 
nated through these organs, and some of its products, such 



436 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

as phenol, kreatin, and extractive materials in general, may 
become positively poisonous, it follows that strongly nitrogen- 
ous foods — the opposite opinion of Oertel and Loewenmeyer 
and their followers notwithstanding — must be abhorred. No 
eggs should be taken, and, as a rule, no meat; now and then an 
exception may be made in favor of veal, spring lamb, chicken, 
fish, or oysters; but, as a rule, the diet in acute nephritis must 
be confined to milk and farinacea. Barley, wheat (stale bread), 
hominy, rice, and potatoes are permissible, also green vege- 
tables and fruit. The beverage consists of water or an alkaline 
mineral water. Lemonade is permissible unless it interfere 
with the digestion of milk. Neither in the acute, nor subacute, 
nor chronic form of nephritis must muscular exertion be al- 
lowed, for it is this that increases the metamorphosis of the 
albuminates. Moderate exercise, however, is not contraindi- 
cated in the chronic form; in the latter the elimination of 
albumin is not increased by exercise. 

The surrounding air is to be fairly warm when the patient is 
in bed, quite warm when he is about. The function of the skin 
must not be suppressed; a moderate amount of perspiration is 
beneficial. Thus it is that there is constant indication for warm 
bathing and a warm climate, for both diminish the labor of the 
kidneys (as also of the lungs). As moist air interferes with 
the action of the skin, a dry climate is preferable. Hot bathing 
must be avoided except in the occasional emergencies of 
uraemia. 

Subacute nephritis with its limpid and sometimes copious 
urine, changeable percentage of albumin, incidental oedema 
and gradual diminution of strength, occasional presence of 
arterial contraction, and of cerebral symptoms, is often over- 
looked. It is a frequent sequela of scarlatina and diphtheria. 
Hot-air and hot-water baths, and iron, which gets deposited 
in the epithelium of the uriniferous tubes (which is thereby 
subjected to premature elimination), should be avoided. Digi- 
talis is contraindicated during high arterial tension; indeed, 



DISEASES OF THE GENITOURINARY ORGANS. 437 

there are but few cases which permit its administration. Small 
doses of opium benefit the circulation in most cases of uraemia 
complicated with high arterial pressure; so do the nitrites 
(nitroglycerin), chloral, and sparteine. Mercury in small doses 
(corrosive sublimate), one-fifteenth to one-tenth grain (0.004- 
0.006), largely diluted (1 : 6000, or 10,000 at least) may be given 
daily, week after week, and may be combined in afebrile cases 
only, with small doses of iron. The air should be warm, a dry 
warm climate selected, a warm bath given every day, with gen- 
tle friction. Large quantities of water, both pure and alkaline, 
should be shunned, for the functional activity of the kidney 
must be diminished as far as compatible with a normal circula- 
tion. This rule is particularly stringent during the presence 
of local or general dropsy. Here the amount of liquid con- 
sumed ought not to be greater than the quantity of urine dis- 
charged. Mild diaphoretics and purgatives will also relieve 
the labor of the kidneys. When the amount of uric acid in the 
urine is persistently large (lithaemic disposition), salicylate 
of sodium may be administered daily, to the total (daily) 
amount of from ten to fifteen grains (0.6-1.0). 

Chronic nephritis is of frequent occurrence. The presence 
of occasional headaches, or of vomiting, or a slow convalescence 
from any ailment, is suspicious, and calls for the. examination 
of the urine. As albuminuria is not always present, and the 
amount of albumin very changeable, that examination must 
be repeated at short intervals and with the best methods; in- 
deed the use of the centrifuge reveals many a case .of alleged 
albuminuria, even of "transient" albuminuria, to be nephritis. 
That albuminuria should be differentiated from peptonuria (in 
leucocytosis, croupous pneumonia, empyema, ulcerative enter- 
itis, and purulent meningitis) is self -understood; also that the 
albumin of pyelitis or pyelonephritis should not be mistaken for 
that of nephritis. The absence of dropsy or oedema proves 
nothing at all, particularly in the very young infant, in whom 
chronic nephritis without dropsy is a frequent occurrence after 



438 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

pleurisy, pneumonia, erysipelas, or in syphilis. Indeed, the 
most dangerous cases are those in which no dropsical symptoms 
are apparent. Many a case of chronic nephritis could be pre--: 
vented by the discovery of the acute or subacute stage preced- 
ing it, and by heeding its many causes. I have seen a number 
of cases complicating or rather depending on purpura, in which 
evidently the presence of small hemorrhages in the renal tissue 
gave rise to the initial irritation. In these cases the constant 
use of phosphorus (one one-hundred-and-fiftieth grain twice or 
three times daily) administered during two or three months in 
succession added greatly to the final recovery. 

Now and then a case of chronic nephritis will recover. The 
majority of those I have seen getting well took corrosive subli- 
mate. The "poisonous" effect of the drug I have not seen in 
such cases; nor in any case where it was watched. Children of 
five years may safely have one-fiftieth or one-sixtieth of a grain 
(0.001) in a tablespoonful of water three or four times daily 
for many weeks in succession. When its intermission is deemed 
advisable, or together with the mercury, iodide of potassium 
may be given in doses of six or ten grains (0.4-0.6) daily. At 
the same time iron may be administered, the chloride (or one 
of the milder preparations), from ten to twenty drops of the 
tincture daily. A gentle stimulation of the kidneys by prepara- 
tions of juniper, or the bitartrate or the citrate of potassium, 
is advisable. Strong irritation of the kidneys must be avoided; 
digitalis is apt to do harm, except in complications with valvu- 
lar lesions of the heart. To increase diuresis through strength- 
ening the action of the heart, sparteine or caffeine render better 
services; the latter, however, should be carefully avoided when 
there are any cerebral symptoms whatsoever. Among the best 
diuretics, through fortifying the heart while diminishing ar- 
terial tension, is nitroglycerin, or other nitrites, the mildest of 
which is sweet spirits of nitre. To combat the latter condi- 
tion, small doses of opium are often useful. In cases of 
obstinate vomiting it is often the only reliable remedy. 



DISEASES OF THE GENITO- URINARY ORGANS. 439 

Chronic nephritis is apt to call for immediate and strong 
measures during some of its worst sequelae. Uraemia (occa- 
sioned by the accumulation of urea in the blood, the presence 
of cerebral oedema, of arterial contraction and heightened 
blood-pressure, and by reflex irritation of the motory centres) 
results in vomiting, diarrhoea, coma, and convulsions. Strong 
purgatives may be required at once (calomel, five to ten grains; 
elaterium, one-twentieth grain, or croton oil, one-twentieth to 
one-tenth grain every hour, to be followed by sulphate of mag- 
nesium), or strong diaphoretics (hot-air bath, hot-water bath, 
hot-water pack, pilocarpine, subcutaneously, in doses of from a 
fifteenth to an eighth of a grain), and occasionally, when the 
symptoms of cerebral hyperemia predominate, a few leeches 
to the septum narium (the preferable place), or the mastoid 
processes, will save a case from imminent destruction. When, 
however, much water is eliminated from the body through all 
these procedures, a new supply must be introduced either by 
the stomach or by the rectum. Injections into the subcutane- 
ous tissue of large quantities of salt-water, which have been ad- 
vised for that purpose, I have not had an occasion to require or 
to recommend. Other sequelae or complications have each their 
own indications; oedema of the glottis cannot wait for the 
effect of the above medication, and demands either scarification 
or intubation. Hydropericardium and hydrothorax require 
paracentesis when the symptoms are urgent. 

The frequency of renal calculi has been alluded to before. 
Indeed, they are quite common, have been observed to occur 
in the foetus, and give rise to many attacks of screaming spells, 
with dysuria, local pain, retraction of the testicles, to the oc- 
casional presence of pus, blood, and gravel in the urine, and 
to vomiting and convulsions. Most of them consist of uric 
acid, very few of oxalates, of cystin (several cases in a family), 
or of the phosphate of ammonium 'and magnesium, and derive 
their positive indications for treatment from their chemical 
composition. Calcareous deposits (carbonates or phosphates), 



440 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

which are found in the newly-born at the lower end of the 
straight canaliculi, near the papillae, and also in epithelia, being 
whitish, have been mistaken for interstitial infiltrations. Cal- 
culi, however, are not only anorganic. The first uric acid in- 
farctions are covered with organic material, and the calculus is 
gradually formed of the mixture of both. Small hemorrhages 
contribute also to it. Indeed, hemorrhages may be both the re- 
sults and the causes of calculi. Meckel spoke of a stone-forming 
catarrh in the kidneys, as we now know that a catarrh of the 
gall-bladder occasions the formation of gall-stones. Particularly 
in those cases which occur in gouty families, the diet has to be 
limited to a moderate quantity of nitrogenous food. Meat may 
be permitted once a day, white rather more than black. Celery, 
parsley, asparagus, and all irritants should be avoided. The 
patients may be encouraged to drink much water, alkaline 
waters to be preferred. All of these contain more sodium than 
potassium; this latter having a greater affinity to uric acid, the 
bicarbonate of potassium, in daily quantities of from ten to 
twenty grains (0.6-1.5), may be given in Seltzer, Vichy, 
Bethesda, Poland, or Waukesha water, large amounts of which 
ought to be administered. The natural lithia waters contain 
less lithia than the occasion calls for; the carbonate of lithia 
taken during a day ought to amount to from three to eight 
grains (0.2-0.5). Thus the artificial lithia waters, if carefully 
prepared, are preferable to those furnished by nature. Piper- 
azin (and lysidin) may be given in three daily doses of from 
two to five grains (0.125-0.3) each. Urotropin is credited with 
the greatest solvent powers of all. In the test-tube it certainly 
has them. I gave it a long time, in alternating periods, to a 
child of two years. Without it, the uric acid appeared in the 
urine as a powder, with it in copious accumulations of needles. 
Urea, in a five- or ten-per-cent. solution, one-half to one tea- 
spoonful three times a day, deserves a trial. 

The presence of a stone in the kidney, besides giving rise to 
the symptoms enumerated above, may produce renal catarrh, 



DISEASES OF THE GENITOURINARY ORGANS. 441 

and secondary catarrh in the ureter and the bladder. When 
it leads to pyelitis or pyelonephritis, the treatment directed 
against their cause should be continued. At the same time 
gallic acid in daily doses of from eight to twenty-five grains 
(0.5-1.5) should be given, and balsamics (cubeb, copaiba) may 
be tried if the stomach permits. Methylene blue (not pyok- 
tanin) I have tried largely and persistently. It reduced neither 
the quantity of pus nor the alkalinity of the urine. Saccharin 
deserves to be tried, from one to five grains daily. When the 
kidney is enlarged and pyaemia threatening, surgical inter- 
ference is called for. Nephrotomy or nephrectomy may save 
life. Pyelitis, when resulting from tuberculosis, indicates ne- 
phrectomy as soon as the diagnosis is beyond doubt. 

2. Bladder. 
Of cystitis, infancy and childhood exhibit every possible 
form, from the catarrhal to the ulcerous or diphtheritic; the 
tuberculous form is very rare in children. It is more frequent 
than Ashby is willing to admit. Exposure to low temperatures, 
chilling of the parts by sitting on cold stones or wet grass, 
trauma, vulvo-vaginitis, the immigration of bacterium coli 
mainly during and after follicular enteritis, the administra- 
tion of cantharides or other irritants, the drinking of beer, 
severe indigestion, constitutional diseases, such as pneumonia, 
gastro-enteritis, meningitis, typhoid fever, variola, or diph- 
theria, and the presence of stone in the bladder, are just as 
many causes. Dysuria, retention or incontinence, vesical and 
rectal tenesmus, the presence of mucus, pus, and blood in the 
urine, fever, and secondary peritonitis or "typhoid" symptoms 
are among the possibilities. Trauma demands absolute rest in 
bed, and either cold or warm applications, besides opium, which 
may be administered internally or in suppositories; exposure 
("cold"): warm bathing, diuretics and a narcotic; the cystitis 
of infectious fevers: rest in bed and tonics; that following 
the use of cantharides (administered internally or in vesica- 



442 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tories): from two to ten grains of camphor (0.125-0.6) daily, 
internally; severe indigestion: the correction of the alimentary 
disturbances by abstinence, purgatives, and plenty of water; 
hyperacidity of the urine: the use of alkaline waters; hyper- 
alkalinity: that of hydrochloric acid; vesical calculus: its re- 
moval, preferably by the suprapubic operation. In most cases 
the patient ought to be kept in bed, apply warm poultices, 
drink plenty of carbonated alkaline water, abstain from cold 
beverages, live mostly on milk and farinaceous food, keep his 
body warm, particularly abdomen and feet, take a dose of calo- 
mel, and an opiate for occasional relief. But by far the best 
symptomatic remedy in the spasmodic pain of cystitis is hyos- 
cyamus; from two to four grains (0.125-0.25) of the extract 
may be taken daily for an indefinite period. The chronic cases 
require the internal use of boracic acid or chlorate of potassium 
(from 15-30 grains daily), turpentine, gallic or tannic acid, 
uva ursi, and salol or salicylates; the latter if there be no 
nephritis at the same time. In a number of instances the local 
treatment of the bladder is indispensable; the bladder may be 
washed out with sterilized warm water, or salt solution 
(6 : 1000), or a warm solution of boracic acid (two or three per 
cent.), or nitrate of silver (one-quarter or one-half of one per 
cent.), or lysol (one-quarter of one per cent.). This procedure 
requires sometimes, particularly in young children, anaesthesia 
by chloroform. 

Some of the symptoms met with in cystitis may occur with- 
out the presence of the latter. Painful spasm during mictu- 
rition, retention of the urine, or incontinence are very frequent 
under the influence of quite a number of different conditions; 
it is upon the causes that the treatment depends. The urine 
may contain, besides a superabundance of uric acid, salts or 
bile, or irritants of a nature which cannot always be determined 
accurately. Thus, urticaria of the surface, when resulting from 
ingesta, is quite often complicated with vesical spasm, so that 
it appears that the same cause acted simultaneously on the 



DISEASES OF THE GENITO UEINAEY ORGANS. 443 

external and internal integuments. Dysuria may also depend 
upon a painful condition of the urethra, resulting from acidity 
of the urine or the transmission of a vulvo-vaginitis, or con- 
genital contraction of the urethral orifice or adhesion (mostly 
acquired) of the labia majora, which is easily corrected, or a 
balanitis resulting from the irritating effect of urine retained 
round the glans penis by phimosis. The indications for treat- 
ment in all of these cases are so plain that the enumeration of 
the etiological factors seems to be sufficient. There are also 
cases of "irritable bladder" as well in the young as in the adult, 
in which the result of the treatment gives sometimes the ex- 
planation of the cause. In a few cases the introduction of a 
catheter was sufficient to relieve the spasm of the neck, in 
others the administration of hyoscyamus proved satisfactory. 

Retention of urine by local atony and paralysis is rare in chil- 
dren, except as the result of hyperextension during school 
hours; still, it may occur in the course of spinal diseases. Now 
and then there are mechanical obstacles. In the newly-born the 
colliculus seminalis is often quite large and requires the intro- 
duction of a sound. Large stones in the bladder, or a smaller 
one near the neck, or one impacted in the urethra, or a string 
tied round the penis and buried in the swollen tissue, or the 
epithelial closure of the urethral orifice, or an oedematous pre- 
puce are more or less amenable to a diagnosis and speedy 
amelioration. The injection of warm or cold water into the 
bladder, warm bathing or hip-bath, the correction of the epi- 
thelial adhesion of the prepuce, and the use of the catheter or 
sound find their ready indications. Eetention during infectious- 
or cerebral diseases requires great attention. Unconsciousness 
is a frequent cause, and frequent percussion of the bladder 
ought to be resorted to when the brain becomes insensible to 
the expansion of the organ. 

Evidently the causes of retention are very numerous; one of 
the most puzzling cases was one in which the accumulation of 
urine was very great. The introduction of an elastic catheter, 



444 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

though it entered to its full length, availed nothing; a metal 
catheter entered with difficulty until it suddenly appeared to 
overcome an impediment and the urine was expelled with great 
force. The autopsy gave the explanation of the singular oc- 
currence. The whole bladder was lined with a thick diphthe- 
ritic membrane, which was easily detached but did not admit 
the elastic catheter. This was deflected along the wall of the 
bladder, while the silver catheter succeeded in perforating the 
pseudo-membrane of the diphtheritic cystitis. 

The great variety of the causes of incontinence of urine re- 
quires tact and discrimination in the election of remedies. 
General anasmia and muscular debility, rhachitis and tubercu- 
losis indicate a diet carefully selected for its nutritiousness and 
digestibility. Gentle massage of the whole body, sponging with 
alcohol and water (1:6) or with water, and efficient friction 
with thick towels, sea-bathing, and the use of medicinal robo- 
rants, such as iron or arsenous acid, will always prove beneficial. 
The elixir pepsini, bismuthi, et strychnine of the National 
Formulary is a good preparation in insufficient gastric diges- 
tion, with atony of the stomach; a child of three years may take 
a teaspoonful three times a day. 

Attention should be paid to the capacity of the bladder. In 
every case, particularly in the evening, the quantity of fluids 
allowed should be restricted. The sigmoid flexure and the rec- 
tum should be empty in the night, and the patient should be 
encouraged to evacuate both bladder and rectum before re- 
tiring. After a few hours' sleep the children ought to be taken 
up and roused sufficiently for both purposes. 

Muscular debility of the neck of the bladder (sphincter) re- 
quires general and local stimulation. The child should be en- 
couraged to hold the urine as long as barely possible. Strych- 
nine or other preparations of nux vomica prove effective to a 
certain extent by improving both the general innervation and 
the appetite; in desperate cases an occasionally subcutaneous 
injection into the perineum (one-fortieth to one-sixteenth 



DISEASES OF THE GENITOURINARY ORGANS. 445 

grain) has rendered good service; an ointment of one part of 
extract of nux vomica in from ten to sixteen parts of fat, intro- 
duced into the rectum (size of a coffee or lima bean) several 
times daily, will also act well and may be continued for some 
time. The same indication is fulfilled by ergot, the fluid or the 
solid extract of which may be employed internally. The in- 
terrupted electrical current is perhaps the most powerful local 
stimulant; one of the electrodes is applied to the perineum, the 
other to the hypogastrium or the lumbar region. The advice to 
apply the negative pole to the interior of the urethra or blad- 
der and the positive somewhere externally is bad, because of the 
danger of urethritis and cystitis. It is particularly those cases 
in which the sphincter is liable to be overcome that the raising 
of the pelvis (by pillows, by raising the foot of the bed) has 
been recommended. The method is quite clever from a me- 
chanical point of view, but the patients are not patient enough 
to sleep that way. 

Whenever there is oxalic acid or sugar or an excess of urates 
and phosphates, or bacteria, in the urine, the source of the dis- 
turbance should be attended to. The digestive disorders form- 
ing the source of the anomalous condition require a correspond- 
ing change in the diet (diminution of nitrogenous food) or 
correction of the functional disorders of the stomach and liver 
by dilute hydrochloric, or nitro-hydrochloric acid, and an occa- 
sional purgative. Until that can be accomplished the prognosis 
is very uncertain. Vesical catarrh, nephritis, and the presence 
of a calculus in either the kidney or the bladder have their own 
indications. From the latter it is removed by the suprapubic 
operation. The hyperesthesia of the body of the bladder, com- 
plicated or not with catarrh, — it is often found without it, — 
requires belladonna or its alkaloid. Both belladonna and atro- 
pine are tolerated in much larger doses by children, in propor- 
tion to their size or age, than by adults. In many cases a single 
evening dose of extract of belladonna (gr. J-J-l = 0.015-0.06) 
or sulphate of atropine (one-one-hundredth to one-seventy- 



446 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

fifth) answers well, sometimes to an unexpected degree. Bro- 
mide of potassium (grs. 6-25 = 0.4-1.75), chloral hydrate (grs. 
2-10 = 0.1-0.6), camphor (grs. 2-5 = 0.125-0.3), extract, 
humuli fluidum (tijj 4-10), or the elixir humuli of the National 
Formulary, in teaspoonful doses, given at bedtime, answer a 
similar purpose. 

Causes of reflex contraction located in the vagina, penis, or 
rectum require local correction. Vaginal catarrh is as obsti- 
nate because of its inaccessibility as it is frequent. Polypoid 
excrescences about the vagina or in the urethra (of the female) 
demand removal; if there be phimosis, circumcision is re- 
quired. But a great many cases which are presented for that 
purpose can easily be remedied by gentle dilatation of the pre- 
puce. Firm adhesion of the prepuce requires careful detaching. 
Intestinal worms must be expelled, and the fact remembered 
that oxyuris has its original seat in the upper part of the colon 
and the lower part of the ileum, so that rectal injections have 
but a temporary effect in most cases. Fissure of the rectum, 
mostly of small size and located posteriorly, requires forcible 
dilatation, — a procedure which demands little time and gener- 
ally no anaesthetic, but is very efficient. 

Irritability of the neck of the bladder and the prostatic part 
of the urethra has been treated by Henry Thompson with cau- 
terization by means of a two-per-cent. solution of nitrate of 
silver. A solution of one part in a thousand of distilled water 
will be found sufficient, or a solution of one or two parts of 
tannin or alum in a hundred. Still, it is a better plan to intro- 
duce either an elastic catheter or a metal sound into the blad- 
der, every few days, for two or four minutes. A few drops of a 
two- or three-per-cent. cocaine muriate solution instilled into 
and distributed in the urethra a few minutes before the in- 
sertion of the instrument will in many cases render general 
anaesthesia superfluous. 

The latter, however, cannot always be dispensed with. In 
the case of a girl of three years, with chronic catarrh of the 



DISEASES OF THE GENITOURINARY ORGANS. 447 

bladder and incontinence, anaesthesia was required a dozen 
times, for two purposes, — first, to inject a solution of nitrate 
of silver (1 : 1000) into the bladder, and, secondly, to dilate 
forcibly, with increasing amounts of water, the organ, which 
had habituated itself not to hold more than a lew drachms of 
fluid at a time. This forced dilatation, under anaesthesia, I had 
to resort to in several cases with fair results. 

Masturbation, which is so frequently the cause of irritation 
of the prostatic portion and thereby of incontinence, has its 
own indications. Its cure is by no means easy. Infants can be 
watched and forcible prevention of self-abuse (more by the 
thighs than the hands) resorted to; but children of more ad- 
vanced years require an unusual amount of firmness and super- 
vision. Bodily punishment will avail but little in the treat- 
ment of incontinence from whatsoever cause, except in the 
diurnal form, when the boy refuses to give up his game, being 
either too much interested or too indolent. 

In a number of cases the removal of adenoid growths, or the 
resection of greatly hypertrophied tonsils have relieved incon- 
tinence. 

3. Other Organs. Anomalies and Diseases. 

The development of the genital organs begins in the sixth 
week of embryonic life; that of the urorectal septum, by which 
the urethra of the penis is formed, about the middle of the 
third month. About the same time the anterior part of the 
urethra is developed by the invagination of the epidermoid 
integument of the glans penis. This invagination extends 
backward to the valvula Guerin in the fossa navicularis. Here, 
where the two parts of the urethra are to meet, the opportunity 
is furnished for the occurrence of many anomalies. 

That invagination may not take place at all. In that case 
there is no indication of an anterior urethra. There may be a 
superficial epithelial obstruction of the urethra after it has been 
formed, with retention of urine behind it; or a partial con- 



448 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

traction or narrowness of the external orifice, particularly in 
cases of genuine phimosis; or a genuine stricture in the pars 
cavernosa, of which instances have been reported by Guyon, 
Englisch, and Demme; or an extensive obstruction mostly 
complicated with rectal anomalies, and retention of urine, dila- 
tation of the ureters and renal pelves; or, finally (in a few 
reported cases), obstruction of the neck of the bladder, with 
the same disturbances unless the urachus be forcibly kept 
open. 

The emission of urine begins about the middle of foetal life. 
Sometimes the connection of the two parts of the urethra has 
not been established; in that case there is a dilatation behind 
the fossa navicularis with a constantly growing lake of urine. 
Its pressure may succeed in breaking through the obstacle with 
or without the formation of a valve, or it will burst the lower 
wall of the urethra behind the obstacle and form a mild form 
of hypospadias. If the urethra be perforated farther back, the 
hypospadias may be scrotal or perineal. That hypospadias may 
occur in this way, and not only by an arrest of development, 
is proven by the occurrence of cicatrices, and such contraction 
as depends on cicatrization only. 

Many of these anomalies are the subjects of surgical interfer- 
ence. Fortunately, all of them are but rare, as the careful 
reports gathered by Kauffmann in "Deutsche Chirurgie," and 
Bohn in "Gerhardt's Manual" will prove. Epithelial obstruc- 
tion of the external orifice can be remedied by puncturing 
and dilatation of the external orifice; one such case I have 
seen thirty years ago, and never since. Membranous obstruc- 
tion in the fossa navicularis has been pierced; even a case of 
foetal imperf oration of the whole glans penis has been perforated 
by Eauchfuss with apparent success. Congenital strictures 
have been treated with bougies. The narrow orifices of hypo- 
spadias should be dilated with bougies, or the knife, or both, 
and laminaria tents used to render the effect permanent. And 
hypospadias has been greatly benefited by operative procedures, 



DISEASES OF THE GENITOURINARY ORGANS. 449 

with better success in modern times than the plastic operations 
of Dieffenbach could boast of. 

The prepuce begins to be evolved about the end of the third 
and in the beginning of the fourth month of embryonic life. 
Within a month afterwards it extends to the middle of the 
glans. Its covering epithelia are pavement. They form from 
six to eight superjacent layers, and extend as far as the urethra 
and sometimes into the fossa navicularis. They are also those 
which constitute the more or less numerous accumulations, 
principally about the corona glandis, which were formerly 
taken to be fat, the so-called epithelial pearls. They are met 
with as early as the fifth month of foetal life. They are some- 
times so large as to raise the adjoining part of the prepuce 
from the surface of the glans and to form small cavities around 
themselves, thus contributing to the spontaneous separation of 
the preputial adhesions. 

These adhesions are vastly more frequently soft agglutina- 
tions than solid unions. The causation is simple: as the pre- 
puce and glans are in close juxtaposition, the epithelia of both 
remain moist, and thus become coherent. It is only in those 
cases in which the prepuce does not snugly cover the glans — 
for instance in hypospadias and epispadias — that no, or but 
partial, cohesion takes place. There are cases, however, in 
which the union of the two surfaces becomes quite firm, partly 
in consequence of the occurrence of an inflammatory exudation, 
and partly because of the existence of an extraordinary amount 
of superficial papillae, which, according to Englisch, grasp and 
join each other. Thus the soft cohesion of the prepuce and 
glans penis is a physiological condition, and therefore met with 
in almost every male child. The degree, however, to which 
it is developed is liable to differ. The prepuce of the newly- 
born being long, it may cover the whole glans down to the 
orifice of the urethra, and then by its overlapping adhesion 
give rise to retention of urine, and in consequence of irritation 
by urine, and of the traction invariably connected with the 

29 



450 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

slightest changes in the shape of the organ during micturition, 
to pain, redness, muco-purulent secretion, sometimes moderate 
extravasation, and erections which again produce a local irri- 
tation of the surface. It is the erections, when frequently 
repeated, and when occurring more normally in later years, 
combined with the effects of the cavities formed round the epi- 
thelial pearls, which usher in the gradual and final separation 
of the prepuce from the glans penis. That process takes place 
between about the ninth and thirteenth year of life. Thus, in 
the vast majority of cases, no interference is required. The 
more gradual the separation takes place the safer it proves. 
It is only artificial disjunction which may become a danger by 
secondary changes. The only reason for interference is in re- 
tention of urine and balanitis, both of which are often found 
together. The separation succeeds in most cases quite easily 
by holding the glans gently but firmly between the fingers and 
pushing or pulling the prepuce in the direction of the corona. 
Towards the end of the operation the pearls make their ap- 
pearance; the separation, however, must be completed without 
interfering with them, and the prepuce then carried forward 
again to avoid paraphimosis; for there will be some slight 
cedema by which the latter might be occasioned. Before that 
is done, the application of vaseline, or zinc or lead ointment, 
or a dust of boracic acid or subnitrate of bismuth, or of a 
mixture of one part of salicylic acid, fifteen of bismuth, and 
twenty of talcum, is advisable. Carbolic acid is contraindi- 
cated because of its tendency to facilitate bleeding, though that 
be ever so slight. In most cases it is best not to repeat the pro- 
cedure for some time, in order not to disturb the healing and 
hardening process. Every wound or tear may bring on cicatri- 
zation and secondary phimosis. In some cases the separation 
does not take place quite readily; in them a blunt probe intro- 
duced between the two layers will overcome the obstacle. 
Probe and fingers will succeed, if care and time be taken, not 
only to accomplish the end in view, but also to avoid tearing, 



DISEASES OF THE GENITOURINARY ORGANS. 451 

bleeding, oedema, and inflammation. The occurrence of cica- 
trization is always a serious matter. I have succeeded without it 
in many more cases than I could take notes of; for the number 
of cases in which the medical man is consulted in reference to 
the advisability of circumcision — which is one of the modern 
onslaughts upon the genito-urinary organs — is very great. 
Twenty-nine out of thirty alleged cases of unconquerable phi- 
mosis are exactly of the kind in which a patient reduction and 
separation prevent both a surgical operation and a surgical fee. 
The solid cohesion which requires the use of the knife, and 
a careful and expert operation, is very rare; I have seen but few 
that were complete in a lifetime. I cannot imagine that a total 
synechia is curable without a plastic operation, or better still, 
the total removal of the prepuce after its separation; for new 
adhesion must follow the operative separation in the absence of 
mucous membrane. 

From what I have said it follows that we cannot recognize 
the existence of an actual phimosis in the young before the 
epithelial agglutination has been relieved. The actual cases 
may exhibit a long or a short prepuce, be partial or total, con- 
genital or acquired, atrophic or hypertrophic. The latter species 
is often dependent on changes in the internal lamina of the 
prepuce, which, when originally contracted and tight, is subject 
to inflammatory and exudative processes; the atrophic form is 
due more frequently to a defective development of the integu- 
ment, which thereby becomes attenuated. Both of these forms 
are liable to be congenital, and either is found as well among 
infants and children as in later life. The degree of the phi- 
mosis depends upon the development of those anomalies, and 
also upon the degree of the presence of the elastic layer de- 
scribed by Reiner and situated between the two laminae of the 
prepuce. 

Phimosis may be acquired by pathological changes of the 
tissue depending on accidental morbid processes. Dropsy may 
so swell the prepuce as to result in it. The frenulum, congeni- 



452 THEBAPEUTICS OF INFANCY AND CHILDHOOD. 

tally short or otherwise, may suppurate and' cicatrize. Inflam- 
mation and ulceration from whatever cause, irritation and tears 
following inconsiderate or unsuccessful attempts at separating 
epithelial adhesions, and the cicatrization of circumcision 
wounds are apt to render the edges of the prepuce unduly rigid. 
The symptoms of phimosis may be both local and general. 
Irritation by contact with urine, and pouching of the prepuce 
by mechanical retention, is quite frequent. Smegma becomes 
rancid when the original epithelial adhesion has been sepa- 
rated. Eetention of urine, or incontinence, or both combined, 
are often met with. The former and the spastic dysuria pro- 
duced thereby result in straining, vesical symptoms resembling 
those met with in vesical calculus, prolapsus of the rectum 
with more or less constant tenesmus, the protrusion of hernia, 
the formation of struma, have been observed. Like balanitis, 
which is frequent, cystitis and hematuria will occur. The local 
irritation gives rise to erection, sexual excitement, and mastur- 
bation in the youngest of infants. Headaches are said to be 
frequent but mostly temporary, and permanent nervous symp- 
toms in great numbers have been attributed to phimosis. It 
has become quite customary, though less so to-day than ten 
years ago, to attribute severe nervous derangements to it. A 
London neurologist has gone so far as to make the statement 
that in twenty-five cases of epilepsy he found congenital phi- 
mosis eleven times. Probably it was the "phimosis" which is 
none, as can be proved by its ready reducibility. The so-called 
reflex paralysis from genito-urinary causes has played and is 
still playing an important (?) part in American pathology. 
Numerous cases of infantile poliomyelitis and cerebral pa- 
ralysis, spastic paraplegia and paralysis, chorea, epilepsy, con- 
tractures, and idiocy have been explained (?) by the presence 
of phimosis. The numerous cases alluded to above of alleged 
phimosis, in which the separation of the preputial adhesion 
and apparent phimosis was easily accomplished, were fre- 
quently such as had been condemned to be operated upon 



DISEASES OF THE GENITO-URINARY ORGANS. 453 

for a serious spinal or cerebral disease. There was a time 
when, in a New York medical society, one of the sponsors of 
the theory of genito-urinary reflex paralysis related cases of 
contracture and convulsions. When reminded that his cases 
were convulsive and not paralytic, he retorted he was no physi- 
ological theorist, but he cured his patients. In another meet- 
ing, years afterwards, I stated that I had never seen a case that 
obliged me to assume a causal connection between paralysis 
or contraction on the one hand, and phimosis on the other, 
and was sustained by neurologists of rank, who also denied ever 
having seen a case which necessitated the assumption of a 
genito-urinary etiology. Still the bugbear is alive, many a 
prepuce is sacrificed, many a fee pocketed, many a diagnosis 
not made, and many a case either procrastinated or not cured. 
Many instances of moderate phimosis are best treated by the 
gentle method of gradual retraction, many are improved by the 
normal erection occasioned by micturition, and other causes. 
Thus it was that dozens of years ago an experienced pediatric 
surgeon, Guersant, could state that he seldom operated for phi- 
mosis before the fourth or fifth year. Forcible dilatation, if 
resulting in fissures of the edge, must be frequently repeated to 
avoid hard cicatrization and consecutive contraction. Many 
such cases, however, are served better by circumcision. Such 
cases as are not amenable to mechanical treatment require the 
knife. The incision of the inner lamina alone, which has been 
recommended, is very apt to be incomplete, though pain- 
ful, and to lead to swelling and imperfect results. The 
atrophic variety requires a dorsal incision by either knife, 
carried on a director, or a pair of scissors; the inner lamina 
is often not thoroughly divided, and requires the repetition of 
the incision; when the scissors cannot be carried over the whole 
length of the glans, it has become necessary to first cut down 
on the corona glandis, thus to enable the operator to carry the 
scissors over the entire length. The cut edges are mostly sub- 
jected to Kocher's continuous suture, and the whole surface 



454 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

treated antiseptically with bismuth (dermatol) and an aseptic 
dressing kept moist with a mild antiseptic, boric or boro-sali- 
cylic (Thiersch's) solution. Iodoform and carbolic acid should 
be avoided. The lower corners are mostly rounded off. This is 
particularly necessary in the cases of hypertrophic phimosis 
which are subjected to the same surgical treatment. Most of 
this class, however, demand complete circumcision, care being 
taken that more is removed of the dorsal prepuce than of the 
opposite side, that the inner lamina is separately divided after- 
wards and the epithelial adhesion carefully separated. The 
prepuce must be drawn forward sufficiently to protect the glans 
against being injured; more than once have I seen it mutilated. 
In one case the mutilated glans became infected with diph- 
theria. The wound must be sutured, and treated antisepti- 
cally. One of the saddest cases of my whole life, and one of 
persistent distress, was the death from erysipelas from that 
simple operation performed on a boy of three years. Infections 
of circumcision wounds by bacteric poisons are quite frequent; 
such of diphtheritic invasions I have published in my treatise 
of diphtheria (1880), and before that in the second volume 
of "Gerhardt's Manual" (1876); many more I have seen since; 
and syphilis and tuberculosis have been known to follow many 
instances of either surgical or, more frequently, ritual circum- 
cision. 

Diphtheria of the prepuce, or rather the genito-urinary 
organs in general, the female included, may occur as an origi- 
nally local affection — such as those alluded to — or a part of 
the general infectious diseases. The latter are mainly diph- 
theria, scarlatina, and measles. The last named is the very 
malady which appears to predispose the system to the most 
vehement forms of local invasions. The aphthous vulvitis of 
little girls, and noma, are mostly found after measles; and 
diphtheria, when found after the same eruption, is more apt to 
destroy life, with general symptoms, than under ordinary cir- 
cumstances. In many cases of localized diphtheria, however, 



DISEASES OF THE GENITO-UEINAEY OEGANS. 455 

the constitutional symptoms are but few, provided that effec- 
tive local treatment is immediately resorted to. Absolute 
cleanliness of the parts, sponging and bathing, is first in order, 
after that, local disinfection. Applications of lime-water will 
suffice for mild cases; solutions of one or two parts of sulpho- 
carbolate of zinc in one hundred of water, or from one- to five- 
per-cent. solutions in water of acetico-tartrate of aluminium, 
will act well. These two may be used to advantage as a vaginal 
injection in the case of the smallest girls. The nozzle of a small 
hard-rubber or glass syringe should be lengthened by a thin 
india-rubber tube, from half an inch to an inch long, which 
passes the hymen easily and permits an irrigation of the 
otherwise inaccessible parts. In many cases solutions of the 
bichloride of mercury proved successful: for occasional appli- 
cations, of one in from three to five hundred of water; for fre- 
quent use, of one in from two to five thousand. In exceptional 
cases, however, it is not well borne and frets the surface. Iodo- 
form as a powder, or in from eight to fifteen parts of vaseline, 
has rendered very effective services. Boracic acid avails but 
little. 

Noma of the vulva and vagina requires more determined 
local treatment, besides assiduous roborant and stimulant ad- 
ministrations. Mineral acids in full strength, strong solutions 
of corrosive sublimate, have proved efficient in many cases in 
which the progress of the disease was not too rapid. I have 
had most successes with the actual cautery, Pyoktanin when 
used in cases of noma of the face, and in those of the vulva, 
was absolutely worthless. 

Paraphimosis results from manipulation. The separation of 
the epithelial congenital adhesion and the dilatation of a phi- 
mosis are liable to be followed by cedematous swelling. In both 
cases the prepuce should be replaced over the glans. If that 
be omitted, the prepuce — relatively long in the child — will 
swell, and may become gangrenous. Fortunately, the penis 
itself is not often drawn into that process. For the purpose of 



456 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

reduction, the glans penis, which is considerably swelled, is per- 
sistently compressed while the prepuce is drawn forward. A 
good deal of force is sometimes required, and not infrequently 
an anaBsthetic. Sometimes gradual compression by bandages 
(cotton or rubber) must precede the attempt at reduction; in 
some cases, however, a careful incision of the prepuce, the more 
careful when no director can be introduced between the glans 
and prepuce, is unavoidable to relieve the constriction. 

The treatment of the more common forms of balanitis and 
balano-posthitis, occasioned by the decomposition of smegma, or 
by masturbation, or gonorrhoea, or trauma, such as the constric- 
tion of the organ by a string, is not always quite simple. When 
there is much oedema it may become necessary to incise the pre- 
puce to get at the sore surface. In most cases, however, as- 
tringent or disinfectant solutions can be applied readily either 
directly or through a small syringe. Solutions of acetate of 
lead, sulphate of zinc, alum, tannin, the sulpho-carbolate of 
zinc, the acetico-tartrate of aluminium can be employed in dif- 
ferent strength, also permanganate of potassium (1 : 1000- 
3000). Among the poor, when assiduous attention is out of 
the question, ointments or powders are preferable. Ointments 
are best made for this purpose with vaseline. Warm bathing 
and sponging with moist absorbent cotton will improve the 
chances of a rapid recovery. 

A similar local treatment is adapted to the vulvar and vaginal 
catarrh of both the adult and the infant or child. It is very 
common among the latter, and quite obstinate because of the 
comparative inaccessibility of the parts, no matter whether 
the catarrh is simple or specific. The causes of the former are 
very various. A predisposition may depend on that structural 
debility, with chronic inflammation, of most tissues, which we 
are in the habit of calling scrofulous. Local exposure to cold, 
sitting on house-stoops, the irritation brought on by masturba- 
tion, or by foreign bodies, mud, cotton, carpet-fuzz, glass, wood, 
all of which I have found in the narrowest vaginas; also oxyuris 



DISEASES OF THE GENITOURINARY ORGANS. 457 

emigrating from the rectum, the use of soiled cloths and towels. 
and the gross neglect of the most urgent cleanliness, with the 
possibility of directly importing bacteria coli, are among the 
most frequent causes of vaginal catarrh. Specific vaginal ca- 
tarrh (gonorrhceal colpitis with its diplococcus) is by no means 
rare. The infection, though most often indirect, and conveyed 
by towels, bed-sheets, but also by immediate bodily contact 
(mostly in institutions which furnish those cases in large num- 
bers as a dispensation of providence), frequently gives rise, even 
in the smallest children, to glandular swellings, endometritis, 
parametritis, salpingitis, oophoritis, and peritonitis, also to ure- 
thritis, though the latter appears to be less common in chil- 
dren than in adults. That contagion should take place through 
the air, according to Bouchard, I have never been able to ob- 
serve. Besides the local treatment, in conformity with the 
details given above, absolute cleanliness of the body and cloth- 
ing, and frequent (general and hip) baths are required. Mas- 
turbation must be guarded against, and foreign bodies sought 
out and removed. Eectal oxyurides require injections with 
water, vinegar and water, or garlic decoctions, or cod-liver oil. 
They must be resumed after an intermission of weeks, because 
of the repeated immigration into the rectum from the upper 
parts of the intestine, where the nematoid has its habitat. In 
gonorrhceal cases the transmission of the virus to the eyes and 
to other persons must be guarded against. To reach the re- 
cesses of the vagina, partial or total removal of the hymen has 
been advised; but I have met with no such necessity. Besides 
the solutions enumerated above, nitrate of silver has been ad- 
vised. I have used it, in solutions of one in from five hundred 
to a thousand, in a number of cases of ulcerative catarrh. In 
some the restitution of the superficial losses of substance ap- 
peared to be more rapid. In stronger solutions and solid 
it has been employed in tubercular ulcerations, in reference 
to which I have no experience. In many cases of vaginal 
catarrh the surrounding parts are sore and suppurating, or 



458 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

eczematous. Lead or bismuth, ointments, or bismuth powder, 
with or without salicylic acid, will effect a cure in that com- 
plication. 

A frequent result of vaginal catarrh of long standing is a 
moderate degree of atresia of the vagina. It is usually of a 
superficial character only, and can be remedied by tearing the 
adhesion with both hands, or by piercing with a probe and by 
dilating the artificial opening. Astringent applications, or such 
of dermatol ointment (1 : 6-8), will prevent the renewal of the 
closure. Diphtheritic inflammation of the vulva and vagina I 
have known to result in pretty firm occlusion. In one case the 
reopening required some force, and the continued use of bou- 
gies and astringent applications to prevent a repetition of the 
union. The imperforate condition of the hymen, mostly con- 
genital, is often the same process of epithelial and inflammatory 
cohesion accomplished during foetal life. According to its 
early or later formation, and according to the presence or ab- 
sence of vaginal complications, it requires either the probe or 
the knife. Such a complication is mostly the result of either 
an arrest of development or of an inflammatory malformation. 
An early adhesive inflammation of the vagina will obstruct it 
in its entire length, or a transverse obstruction of the ducts of 
Miiller may produce an absence of the vagina below the ex- 
ternal os uteri. 

Vaginal hemorrhage, of a mild degree, has been observed 
in the newly-born, without any complication, least so with 
bleeding from other organs. It is mostly very slight. In mas- 
turbating infants and children, and in some of those who suffer 
from a severe vaginal catarrh, some blood may be noticed. It 
requires no special treatment; nor was there an indication or 
an opportunity to interfere in the very rare cases of genuine 
menstruation in the very young, which have been reported. 

In connection with vaginal catarrh I mentioned masturba- 
tion as one of the causes. Still, it is not only a cause in some 
cases; in many others it is its effect. Indeed, masturbation is 



DISEASES OF THE GENITO URINARY ORGANS. 459 

so frequent that a few words on the subject may be deemed 
permissible at this place, in addition to my former discussion 
of the subject (Arch. Ped. y April, 1890, and Amer. Journ. Dis. 
Ch. and Women, 1875). That habit is very frequent in infants 
and children; more in girls of the earliest infancy, more in boys 
of advancing years, and there is a variety of causes leading to 
it. Such are local irritation (sometimes by nurses) of the geni- 
tals in the very youngest, excitation in those older, feather- 
beds, excess of animal food, and stimulating beverages, rancid 
smegma, eruptions on the penis, vaginal and vesical catarrh, 
renal calculi, preputial adhesion, phimosis, oxyuris, and con- 
stipation. Among remedies, I recommend the relief of the 
causes as enumerated, and partly alluded to on previous pages: 
cooling diet and cool coverings, attention to the kidneys, blad- 
der, and rectum, relief of external irritation caused by clothing, 
mainly by misfit trousers, immediate removal from the bed 
upon awakening, cold bathing and sponging, mechanical pre- 
vention, and timely punishment. 

Cryptorchis is the absence of the testicle from the scrotum. 
Normally it descends in the ninth month of utero-gestation, or 
during the first weeks of extrauterine life, but sometimes at a 
later period, or not at all. In the latter case, particularly when 
incarcerated in the canal, it is apt to undergo in later life ma- 
lignant degeneration. When in its descensus it gets under the 
femoral arch, resembling a crural hernia, or to the perineum, it 
is subject to inflammation, and requires the application of ice, 
and occasionally a local depletion, or a puncture for the relief 
of effusion; and sedatives for the removal of reflex convulsions. 
In most cases of incomplete descensus the testicle is found in 
the inguinal canal, and slightly movable; it may be complicated 
with hernia. No matter whether this complication is present 
or not, the treatment consists in the application and constant 
wearing of a truss so adjusted as to keep the testicle below and 
the intestine above. Its effect can be enhanced by frequent 
and gentle massage. This simple treatment, if started very 



460 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

early, I have found effective in so many cases that Ashby and 
Wright's advice — not to rely on it, but to operate and either 
fix the testicle below or remove it altogether — appears to me 
inappropriate in the very young. If, however, a result has not 
been accomplished in time, or if no attention was ever paid to 
the anomaly, it should be urgently advised to perform orchid- 
opexy between the tenth and fourteenth year (before puberty). 
If that be done the testicle will develop; if not, its atrophy is 
inevitable, or malignant degeneration may take place. 

Orchitis is occasionally found in children. The acute form 
is either traumatic, or alternates, even in the infant, with 
parotitis; or no cause is obvious. The treatment has to be con- 
ducted on general principles, and consists in the local use of 
ice, of purgatives, and, occasionally, of antipyretics and nar- 
cotics. Leeches resulted, in a few of my cases, in extensive 
swelling of the scrotum. Chronic orchitis is mostly combined 
with epididymitis, the result of trauma combined with a scrofu- 
lous disposition. It is apt to lead to induration, caseation, and 
tuberculization. If that occurs, the organ ought to be removed 
to avoid general tuberculosis. 

Primary tuberculosis appears to begin mostly in the epididy- 
mis, and requires removal, as well as dermoids, sarcomata, and 
carcinomata. Of the latter, I saw a case in a boy of four years. 
It was removed and no new local trouble arose; not even in 
the lymph-bodies of the neighborhood. But the disease reap- 
peared in the lungs. Both testicles and ovaries are more sub- 
ject to congenital tumors than perhaps any other organ, with 
the exception of the kidneys. 

Syphilis of the testes requires a strict antisyphilitic treat- 
ment. There is the indication for the internal administration 
of mercurials and iodides; in the first few weeks a daily 
hypodermic injection of a soluble mercurial salt will improve 
the chances of recovery. 

Hydrocele is a frequent occurrence. A few drops of serum 
are normally found in the tunica vaginalis propria. Larger 



DISEASES OF THE GENITOURINARY ORGANS. 461 

accumulations of serum are met with in more than ten per 
cent, of all male infants, — mostly on the right side, seldom 
on both. In the majority of cases there is no longer a com- 
munication with the abdominal cavity. When it remains, a 
hernia may complicate the hydrocele, and the diagnosis may 
be more difficult because, in such a case, the fluid is apt to re- 
turn occasionally into the abdomen. Spontaneous absorption 
is not very rare, but suppuration uncommon. I have injected 
alcohol and diluted tincture of iodine, and setoned the scrotum 
with either silver wire or silk. All of these methods are bad 
to begin with. Simple punctures, one or more, made once or 
repeatedly with a sterilized needle or trocar, will allow the 
escape of the fluid, which frequently does not return after the 
first procedure. It is best to dislodge the integument a little, 
so as to have no direct escape of the serum. If there be a re- 
lapse, however, after a number of punctures, the injection of 
a small amount of tincture of iodine, or of Lugol's solution, 
or of two or three drops of carbolic acid, after the fluid has been 
withdrawn, will prove successful. Radical operations (Volk- 
mann, Bergmann) are rarely required. The cases in which the 
communication with the abdominal cavity is still patent require 
the application of a truss after the serum has been allowed to 
previously return to the abdomen, or a radical operation (Bas- 
sini). 

The pseudoplasms of the young female urogenital organs 
offer no special indications of their own. Tumors of the ovaries 
were mostly found, on operation, to be dermoid cysts, and 
very rarely carinomatous or tubercular. The latter and sar- 
coma, of which d'Arcy Power collected from literature twenty- 
five cases (St. Barthol. Hosp. Rep., xxxi.), are but rare occur- 
rences in the young vagina. Cysts have sometimes been found 
above the hymen, and soft polypi more frequently in the ure- 
thra. They are either easily recognized or mistaken for a sim- 
ple prolapse of the urethral mucous membrane. They give rise 
to vesical tenesmus and dysuria sometimes, and also to (mostly 



462 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

slight) hemorrhages. Evulsion, chromic acid, the scissors, and 
the actual cautery, now and then two of these means combined, 
have been used. Ligature never succeeded in my hands. It 
would always cut through at once, produce some bleeding, and 
necessitate some other method. 



IX. 

DISEASES OF THE RESPIRATORY ORGANS. 

1. The Nares. 

Acute nasal catarrh (acute catarrhal rhinitis) is found either 
as a sporadic or an epidemic ailment; the latter is rarely de- 
pending on erysipelas, still less frequently on gonorrhoea, more 
frequently on influenza, measles, or whooping-cough. The 
mere presence of endless microbes of different varieties is of 
no account; as long as the surface is fairly intact, the nasal 
mucus is bactericidal to a great extent, and invasion does not 
mean infection. The sporadic form is sometimes local and uni- 
lateral; in that case it has a local cause, such as a traumatic 
lesion, or a foreign body; when bilateral and general, it is 
mostly the result of sudden thermometric or barometric 
changes, or exposure to dust, impure or dry furnace air, etc. 
In rare cases the irritation of trifacial branches of the maxillae 
will, when dentition is abnormal or unusually difficult, give 
rise to vasomotor and secretory changes of the nasal mucous 
membrane, which is supplied with ramifications of the same 
nerve. Acute nasal catarrh may be attended with high tem- 
peratures, considerable swelling, and obstruction (thus ren- 
dering respiration extremely difficult, particularly when the 
patient is newly born or quite young), and with secondary 
affections, such as swelling of the cervical lymph-bodies, acute 
pharyngitis, amygdalitis, conjunctivitis, otitis, headaches, and 
sleeplessness. The indications for treatment are various: the 
local hyperemia and swelling is to be reduced,, the secretion 
to be removed, the fever to be relieved, and secondary affec- 
tions either to be prevented or treated, among them all those 

463 



464 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

occasioned by the unfiltered condition of the air admitted 
to the respiratory organs through the month. 

Hyperemia and swelling may prove dangerous to very yonng 
babies. In them the nasal cavities are narrow, and so easily 
obstructed by an acute catarrh that now and then a newly-born 
infant that has not yet learned how to breathe through the 
mouth in which the tongue is curled up, is in danger of suffo- 
cating. Some of the cases require constant attention; day and 
night the mouth must be kept open by gentle pressure on the 
chin to enable the little patient to breathe through the mouth 
until the nares become pervious. Particularly in cases where the 
mucous membrane is thickened from birth, or a nasal polypus is 
present, or a swelling of the pharyngeal or the palatine tonsils, 
and adenoid enlargement, the danger of suffocation is great. 
In a single case have I been compelled to apply the galvano- 
cautery to the left nasal cavity of a newly-born whose acute 
catarrh obstructed the narrow channel. Astringent solutions 
are indicated for a similar purpose, or ointments which may be 
applied by means of a camel's-hair brush. Still, I cannot ex- 
press much satisfaction at the effects obtained. Better is a two- 
per-cent. solution of hydrochlorate of cocaine, which may be 
applied with a brush, or by means of the atomizer, from time to 
time. Camphor inhalations have been praised. The secretion 
must be removed now and then by wiping out the nose and 
bringing on sneezing. The wiping out may be done with a 
probe covered with absorbent cotton, the latter to be introduced 
dry, or moistened with an alum or cocaine solution. The pas- 
sage may also be kept open by a physiological salt solution 
(1 : 150), or an astringent, or a disinfectant wash of alum, sul- 
phate of zinc, subnitrate of bismuth, or boracic acid. The 
latter is not always satisfactory. In most cases, it is true, it 
acts very mildly, but I have seen catarrhal secretions increased 
by it. These applications may be made in different ways. An 
atomizer, when the nozzle is covered with a short piece of india- 
rubber tubing, will do no harm; injections should be made 



DISEASES OF THE RESPIRATORY ORGANS. 465 

very gently, else they are liable to injure the ear; irrigation 
by merely emptying a pipette or a small spoonful of a solution 
into the nostril will prove uniujurious, but not very efficient. 
Otherwise the rational general treatment of a catarrh may be 
resorted to: moderate temperature of the room (68°-74° F.), 
moist air when the secretion is thick and viscid, or scanty, an 
occasional warm bath, a dose of quinine about noon if there be 
a considerable rise of temperature in the afternoon, an occa- 
sional dose of phenacetin or antipyrin during the day or small 
doses of the tincture of aconite at intervals of two hours; prob- 
ably a single dose of opium as a sedative and diaphoretic, late 
in the evening. 

Chronic nasal catarrh derives its therapeutical indications 
from its many occasional causes; for instance, frequent returns 
of acute catarrh, dusty, cold, and moist air, the presence of a 
foreign body, or the deviation of the septum. This latter con- 
dition may be congenital, even hereditary, or due to a fracture 
of the septum, or to its dislocation from the ethmoid, or vomer, 
or superior maxilla. It results in obstruction, and behind it 
in accumulation of mucus which is disintegrated and irritates. 
Other causes of chronic nasal catarrh are enlarged tonsils, 
chronic pharyngeal catarrh, and adenoid vegetations, with 
their damaging influence on respiration, digestion, the sense of 
smell and taste, and intellectual development. Scrofula, tu- 
berculosis, and syphilis, with their effects on mucous mem- 
branes, bones, and cartilages, are frequent causes of chronic 
nasal catarrh. Less frequent are the effects of furunculosis, 
which is rarer than in the adult; of croupous inflammation; of 
diphtheria of the nose, which may be met with independently 
of pharyngeal diphtheria or may usher it in; or of eczema of 
the upper lip. 

Syphilis, tuberculosis, and scrofula have their own indica- 
tions. Thus, a chronic rhinitis occasioned by them demands 
mercury, arsenic, creosote, cod-liver oil, iron, phosphorus, ac- 
cording to general rules. Abscesses are to be opened, the small 

30 



466 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

furuncles incised, necrotic bones removed. Foreign bodies 
must be extracted, adenoid vegetations removed, and hyper- 
trophied tonsils resected, or — in occasional cases — treated with 
the galvano-eautery. Many a case of chronic nasal catarrh will 
be relieved, or nearly cured, by these measures, or, on the 
other hand, there is many a case of chronic pharyngitis which 
gets well through the treatment of the nasal catarrh. Indeed, 
there are very many of these complications in which the de- 
termination of the primary seat of the affection is very difficult, 
or even impossible. If there be a considerable deviation of the 
septum, not to speak of the excessively rare cases of bony 
union, it must be corrected. In very young infants that correc- 
tion can be accomplished sometimes by manual pressure. The 
cleansing of the nasal cavities is of at least as much importance 
as in acute catarrh. They must be washed out from two to four 
times a day with some warm fluid. According to the case, this 
may be salt-water, or a solution of boracic acid (two to four 
per cent.), or alum (half per cent.), or acetico-tartrate of alu- 
minium (one per cent.). The same precautions should be used 
which were advised above. If larger quantities of the fluid 
be used the injection should be made very gently, and the 
child taught to keep his mouth comfortably open. Chlorate 
of potassium has been used in solutions of from one to three 
per cent.; resorcin, of two per cent.; creosote has been applied 
similarly; iodine or tannin, in combination with glycerin. Co- 
caine solutions have been employed with good results. Its im- 
mediate result is evident, but it is better than a merely tem- 
porary makeshift. What I have seen to do a great deal of good 
is nitrate of silver. A solution of 1 : 250-2000 may be sprayed 
into the nasal cavity once a day, or every other day. When a 
carious bone is underlying the chronic catarrh, an iodoform 
ointment (1 : 8 or 15 vaseline) may be applied several times a 
day, to advantage. Hypertrophy of the mucous membrane and 
submucous tissue, with ulcerations or granulations, add greatly 
to the difficulties of the case. Lactic acid in powder or in 



DISEASES OF THE RESPIRATORY ORGANS. 467 

strong solutions has the reputation of destroying morbid tissues, 
mainly granulations, and of leaving the healthy tissue intact. 
Still, I cannot say that it has rendered me very appreciable 
service in cases I considered adapted to its alleged powers. The 
exuberant tissue will, however, be beneficially influenced by an 
application, every few days, of a solution of iodine (1:8 or 
1 : 4), of iodol or aristol, of subnitrate of bismuth, of a strong 
solution (ninety per cent.) of carbolic acid every four or five 
days, of chromic acid once every week or ten days, and last 
and best, of the galvano-cautery under cocaine anaesthesia. 
For the purpose of compressing the swelled soft tissues and cor- 
recting a deviation bougies are also used, made with zinc, tan- 
nin, or carbolic acid. Chromic acid and the galvano-cautery 
are my preferences in the worst classes of cases. Even many 
cases of ozaena are doing well under their influence. Others 
require the frequent use of stronger solutions of nitrate of sil- 
ver as a spray, or hypermanganate of potassium solutions 
(1 : 1000-2000), or acetico-tartrate of aluminium in one- to 
three-per-cent. solutions, or iodol or aristol insufflations, or a 
combination of a few of these remedies. For the purpose of 
cleaning the nasal cavities docile children may learn how to 
employ the nasal douche for copious irrigation. The douche 
(fountain syringe) should not be raised more than a foot above 
the level of the nose, the fluid should be mild (salt water) and 
nearly of the temperature of the body, the head gently bent 
forward, the teeth parted, and respiration should not be inter- 
rupted by swallowing or coughing. If this happen, the tubing 
of the instrument should be momentarily compressed. The 
nozzle should be introduced horizontally into the narrower 
nostril. If sneezing comes on, it should take place while the 
mouth is kept open, and blowing the nose should be done with 
one nostril open. 

Polypi, either congenital or acquired through chronic ca- 
tarrh, though not frequent, will be met with in every medical 
practice. They are either soft and consist of mucous membrane, 



468 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

or harder and are composed of a dense connective tissue. 
Those with an admixture of sarcomatous tissue (not often 
round cells, more frequently spindle-shaped cells with copious 
stroma) are relatively rare. The cold or galvano-caustic snare 
is required by those which have a rather bulky pedicle. Evul- 
sion with a common polypus-forceps suffices for those which 
are distinctly pedunculated, and for such as consist in the main 
of mucous membrane. A firm tampon is seldom required by 
excessive hemorrhage after evulsion. In most cases the bleed- 
ing ceases spontaneously; or a tampon of moderate size covered 
with powdered alum or tannin is demanded; or the cauteriza- 
tion of the stump with chromic acid, either dry or in a concen- 
trated solution, by means of a camel's-hair brush or a probe 
covered with absorbent cotton. This application may be re- 
peated after a while to guard against a return. 

Foreign todies are often found in the nasal cavities of babies 
and children. Paper-balls, shoe-buttons, dry peas and beans, 
flies and bugs, cherry-stones, and beads are readily admitted. 
Their diagnosis is by no means always easy. Chronic catarrh, 
being their usual result, gives rise to the mistaken diagnosis 
of caries, syphilis, or tumor. The cases in which the presence 
of a foreign body causes delirium and convulsions, and may be 
taken for meningitis, are, fortunately, rare. In many, chloro- 
form anaesthesia is required to ascertain the nature of the dif- 
ficulty. The consecutive catarrh and ulceration require mild 
or disinfectant washes or injections. The ear-spoon, or Daviel's 
spoon will generally suffice to dislodge the foreign body. 
While the child is firmly held, the operator standing a little be- 
hind and on one side of the patient, introduces the instrument 
from above downward, the cavity looking forward. In this way 
the foreign body is easily scooped out. When the symptoms 
are urgent (convulsions, high fever), an ala nasi has been in- 
cised to facilitate the required extraction. Dr. G. Bieser recom- 
mends the following method (Ped., July 15, 1897): The child 
is placed in the ordinary position for intubation, the assistant 



DISEASES OF THE RESPIRATORY ORGANS. 469 

holding his hand firmly over the child's mouth. One end of a 
piece of rubber tubing is snugly inserted into the nostril op- 
posite the one holding the foreign body, the other end is in- 
serted into the operator's mouth. The operator then blows 
suddenly and vigorously into the nostril and dislodges the 
foreign body. This method should not be employed, however, 
if it be too firmly impacted; for in that case forcible insuffla- 
tion might injure the middle ear. In every case the mouth 
should be tightly closed. 

Epistaxis depends on the rupture of one or more blood-ves- 
sels, either large or small, normal or abnormal. A normal 
blood-vessel may bleed in consequence of a traumatic injury, 
or of an erosion by chronic catarrh, ulceration, diphtheria, or 
syphilis. Bleeding from the nose may point to the presence 
of a polypus, or be the indication of obstruction in distant 
parts of the circulation in the abdomen, the lungs (chronic 
pneumonia, emphysema), the thyreoid body, or by cardiac dis- 
ease. The compression of the abdominal viscera by enforced 
confinement in the school-room, overheated and ill-ventilated 
at that, and consecutive constipation are a frequent cause of 
epistaxis. Blood-vessel walls become abnormally fragile in 
constitutional and infectious diseases, such as early chlorosis, 
tuberculosis, haemophilia, leucocythsemia, general amyloid de- 
generation; in purpura, scurvy, and typhoid fevers. Perhaps 
the most obstinate form of epistaxis, which is fortunately in- 
frequent, is that which depends on the congenital incompetency 
of the heart combined with smallness of the large arteries, and 
results in the most serious cases of chlorosis. All these dif- 
ferent causes of epistaxis suggest their own indications. The 
constitutional diseases resulting in local hemorrhage demand 
such management as has been indicated in other parts of this 
book. All of them may require local treatment. It is obvious 
that in every case of epistaxis the congestion of the nasal mu- 
cous membrane must be diminished if possible, and the forma- 
tion of a clot should be facilitated. By raising the arms over 



470 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

the head, and by forced inspiration, the chest is expanded and a 
large amount of blood accommodated in it; hot hand- and foot- 
baths have been resorted to for a similar purpose. Ice may be 
applied to neck and throat, pieces of ice introduced into the 
bleeding nostril. The local use of water (injection, washing) 
is not desirable, inasmuch as it is liable to prevent the coagula- 
tion of the blood on the bleeding surface. Solutions of alum 
or tannin will answer better. The use of a tampon is often 
required to stop the loss of blood. The introduction of a wick 
of absorbent cotton, or lint, by means of a pair of fine pincers, 
or, better, by loosely wrapping it round a smooth probe (whale- 
bone or other), or of the same covered with alum or tannin, or 
soaked in a solution of perchloride or subsulphate of iron 
("haemostatic cotton"), combined with pressure from outside, 
or in an antipyrin solution (twenty to fifty per cent.), with or 
without tannin, will sometimes prove satisfactory. In but a 
few will it be found necessary to close the whole cavity from 
either side, by means of a tampon introduced through the 
mouth into the posterior nares, at the same time obstructing 
the nose anteriorly. Bellocq's tube should not be used for that 
purpose, as it tears or. cuts the tissue. An elastic catheter is 
easily carried through the nose and mouth, and the tampon 
attached to it. This procedure is not so annoying and irk- 
some as it appears to be, because it is in few cases only that 
nose-bleeding is bilateral. In rebellious cases of older children 
the local cause should be looked for, — viz., an ulceration ex- 
tending into blood-vessels. Ulcerations of the septum narium 
are not frequent in children, but they will occur. 

Chronic catarrh and ulceration of the nares must be treated 
according to the principles taught above, and the most frequent 
causes of epistaxis among children attended to according to 
their own indications. I cannot impress too much the neces- 
sity of attending to the intestinal congestions and disorders of 
school-children. Constipation of a lifetime is often the result 
of the cramped position on an improper chair or bench, and of 



DISEASES OF THE RESPIRATORY ORGANS. 471 

the inability to evacuate the bowels at the proper time. Chil- 
dren suffering from constipation, particularly those who are 
affected with what I have described as congenital constipation, 
may require this daily injection and may be benefited in urgent 
cases by an occasional (vegetable) purgative. This is sometimes 
all that is required to relieve their epistaxis. That many are 
relieved only when taken from school and allowed the free use 
of their limbs in open air is self-evident. Another large class 
of nose-bleeders is that which originally suffered from chronic 
pneumonia or chronic heart-disease with general and persistent 
anaemia. Very many of these cases improve instantly under 
the sufficient use of digitalis and iron. 

2. The Larynx. 
Acute laryngeal catarrh, acute laryngitis, is too common a 
disease to justify a discussion on these pages of its etiology or 
diagnosis. In regard to the latter, I refer to a single point only, 
— viz., that of the temperature, which is always elevated. An 
uncomplicated acute laryngeal catarrh is always attended with 
fever, while an uncomplicated laryngeal diphtheria ("pseudo- 
membranous croup") is not so accompanied. Dozens of years 
ago I brought out this fact, and a large experience has since 
convinced me of its reality. The other symptoms are unmis- 
takable, from the different degrees of dyspnoea to those of 
hoarseness or aphonia, and the barking cough, which is quite 
characteristic and easily differentiated from that of other dis- 
eases of the respiratory apparatus, or from the reflex cough of 
foreign bodies in the naso-pharynx or in the ear. The treat- 
ment requires the most perfect possible rest. Talking must be 
prohibited, crying avoided if feasible. For that reason, if for 
no other, opiates are indicated; partly to relieve the local irri- 
tation which produces cough, and partly to secure sleep for the 
purpose of equalizing circulation and resting the excited mus- 
cles. The temperature of the room ought to be equable, from 
68° to 75° F., the air moist. The latter eases the large wind- 



472 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

pipes and procures rest, while dry and cold air increases the irri- 
tation. Whatever beverages are given should be warm. A 
general warm bath, warm applications (hot water, poultices, 
cold applications which are permitted to become warm), are 
both pleasant and beneficial. Plenty of water ought to be fur- 
nished, mild alkaline mineral water by preference. An infu- 
sion of ipecac with bicarbonate of sodium, in small and 
frequent doses, will aid in liquefying a viscid mucous secretion. 

The worst form of the acute catarrh of the larynx gives rise 
to attacks of dyspnoea ("croup"), which occurs quite frequently 
in the night after the children have been asleep for some hours. 
The drying up of the pharyngeal mucus is very apt to give 
rise to both cough and dyspnoea, and therefore it is a good plan 
to wake the patient from time to time sufficiently to make him 
drink. Average moisture of the air may not be enough. Water 
ought to be kept boiling constantly, so as to fill the air of the 
room (or a tent, which ought to be spacious) with steam. 
Spraying the throat with cold water is useless compared with 
the effect of warm vapors. That leeches, which I used some- 
times in bad cases of feverish and croupous catarrh, thirty 
years ago, ever resulted in any good I am not prepared to say. 
But a promptly administered emetic (ipecac, sulphate of zinc 
or copper, turpeth mineral, apomorphia) has often relieved the 
spasmodic dyspnoea accompanying these (mostly nocturnal) 
attacks of pseudo-croup. The effect of emetics, however, and 
their indispensability have often been exaggerated. Mostly, 
they are less required for the relief of the babies than for tran- 
quillizing the fears of the mother and allowing the family 
physician to stay in bed. 

Chronic laryngeal catarrh may develop out of a protracted 
acute catarrh, or the affection may be primarily mild, but result 
at an early time in the thickening of tissue. Even at the earli- 
est age this process may be observed. One such case I saw with 
Dr. Hopkins, of Brooklyn, in a newly-born baby, which got 
well after the protracted daily administration of a few grains of 



DISEASES OF THE RESPIRATORY ORGAN'S. 473 

iodide of potassium, but after several months only. Constant 
warm applications, or cold ones which are permitted to become 
warm, will favor absorption. Those which are complicated 
with, or perhaps dependent upon, a chronic pharyngeal catarrh 
are often favorably influenced by the use of tincture of pini- 
pinella saxifraga, half a drachm or a drachm of which may be 
taken daily, in ten or twelve doses, in a solution of chlorate of 
potassium, in such a way that the dose of the latter be a cau- 
tious one, and the dilution (in water) of the tincture be not ex- 
cessive. This drug has long been "obsolete," but deserves to 
be reappointed to its former place in practice. The majority 
of such cases will do well when being treated with solutions of 
bicarbonate of sodium or iodide of potassium, also of chloride 
of ammonium in daily doses of from eight to thirty grains 
(0.5-2.0). 

Diphtheritic Laryngitis, Pseudo-Membranous Croup. — It is 
not necessary to discuss here pathological questions, or to re- 
assert the histological identity of diphtheria and "croup." 
When phanmgeal diphtheria has reached the larynx in its de- 
scent, or bronchial diphtheria resulted in its ascent in sudden 
laryngeal stenosis, the usual antidiphtheritic treatment avails 
but little. That neither general nor local depletion has any 
effect, except that of hopelessly reducing the patient's strength, 
has long been recognized; also, that vesicatories add a new 
diphtheritic membrane on the surface to those on the mucous 
membranes. Emetics are of no use unless a peculiar flapping 
sound betrays the presence of half-detached membrane in the 
air-passages. In such a case they are apt to save life. At all 
events, I have never been so fortunate as to observe the univer- 
sally beneficent effect attributed to their frequent administra- 
tion in an average case. Massage of the larynx has been recom- 
mended by Bela "Weiss. I cannot say that the few cases in 
which I advised the procedure were successful; it may be that 
the constant repetition of the advice to use mercurial or other 
ointments over the larynx is based on the observation of an 



474 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

occasional good effect of the friction ("massage") attending 
their employment. Locally, lactic acid, in more or less satu- 
rated solution, has been eulogized as a solvent of the mem- 
branes in the larynx, when often applied either by brush or 
spray. Most of the cases in which I have seen it used were not 
successful, but this untoward result is, unfortunately, not ex- 
ceptional. I have seen, or believe I have seen, papayotin (1) to 
dissolve membrane when applied in a mixture of glycerin and 
water (aa 2). Particularly would that occur in pharyngeal 
diphtheria slowly descending. Lime-water is still used as a 
spray and has its admirers. Lime slaked in a small room, or 
under a tent, is decidedly more effective, for during that pro- 
cess a large quantity of lime is carried up and is inhaled; at the 
same time the softening and solvent effect of the steam is 
obtained. The latter is not always as beneficent as it appears. 
In many the application, externally, of cold water to the neck, 
or ice-bags, is vastly preferable. But in most cases of anaemic 
and highly-nervous children the latter are not tolerated. Con- 
stant inhalations of turpentine, or carbolic acid, from a kettle 
containing boiling water have impressed me as beneficial in a 
large number of cases. Inhalations, in a small room, or under 
a tent, of calomel, which is sublimated in doses of eight or ten 
grains (0.5), every hour or in longer intervals, are certainly 
effective. 

The patient remains in bed as much as possible, and may 
continue such expectorants as he perhaps took for previous 
catarrhal symptoms; may also take diaphoretics and warm bev- 
erages; an occasional opiate for that indication and to procure 
some rest. The continuation of chlorate of potassium, when 
the invasion of the larynx is complete, is rather superfluous. 
Antipyretics are out of the question unless there is a very 
high temperature depending on a complication (general diph- 
theria, pulmonary inflammations). Pilocarpine injures by de- 
bilitating the patient; the cases which are really benefited by 
it are excessively rare. Mercurials have resulted in more actual 



DISEASES OF THE BESPIEATOEY OEGANS. 475 

recoveries than any other internal treatment. The cyanide 
and iodide have been recommended. For nearly twenty years 
I have employed the bichloride in doses of a milligramme (one- 
sixtieth grain) or more once every hour. The smallest babies 
take one-fourth or one-third of a grain daily for days in suc- 
cession easily. Almost never will a stomatitis follow, and no 
gastric or intestinal irritation, provided the dilution be in the 
proportion of at least one in eight thousand. An "occasional 
slight diarrhoea may require the addition of a few drops of 
camphorated tincture of opium. I can repeat a former state- 
ment, that never have I seen cases of croup getting well in such 
numbers, either without or with tracheotomy or intubation, as 
with mercurial treatment. When this treatment proves unsuc- 
cessful, intubation or tracheotomy must be resorted to. A 
small, frequent, and intermittent pulse, aphonia, cyanosis, and 
marked retraction, with every inspiration, of the supraclavicu- 
lar fossae and the epigastrium, are the indications for the opera- 
tive procedure. I shall not here be tempted to defend the two 
operations; I shall not even be tempted to discuss the crimi- 
nality of allowing a child to suffocate without resorting to 
mechanical relief; or to compare the two operations with each 
other. I can only say that for years I have not seen a case in 
which intubation would not take the place of tracheotomy, and 
have therefore not performed the latter. Intubation has come 
to stay; it is not one of the many temporary devices which 
have been brought out to be instantly forgotten. In most cases 
it takes the place of tracheotomy; in none does it make it 
impossible when required in the opinion of the operator. The 
latter operation may be preferred or become necessary for the 
purpose of getting at the trachea and bronchi for the mechani- 
cal removal of membrane and other local treatment, rare 
though the cases be in which such procedures are attended 
with success. It is probable that the many secondary trache- 
otomies which are still performed in Europe when intubation 
is alleged to be insufficient, will not be considered requisite in 
the future. 



476 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

In the consideration of pseudo-membranous laryngitis it 
should not be overlooked that in the vast majority of cases the 
Klebs-Loffler bacillus is found; and that all of these are, there- 
fore, fit subjects for the use of the diphtheria antitoxin. Since 
its introduction both general and local (laryngeal) diphtheria 
have been greatly benefited* In its Washington meeting of 
May, 1897, the American Pediatric Society received, the "re- 
port of its committee on the collective investigation of the anti- 
toxin treatment of laryngeal diphtheria in private practice/' 
Its salient points are as follows: The number of cases reported 
during the eleven months ending April 1, 1897, was 1704, — 
mortality 21.12 per cent. The cases occurred in the practice 
of 422 physicians in the United States and Canada. Operations 
employed: Intubation in 637 cases, mortality 26 per cent.; 
tracheotomy in 20 cases, mortality 45 per cent.; intubation 
and tracheotomy in 11 cases, mortality 63.63 per cent. Num- 
ber of States represented 22, besides the District of Columbia 
and Canada. Non-operative cases 1036, mortality 17.18 per 
cent.; operated cases 668, mortality 27.24 per cent. Two facts 
may be recalled in connection with these statements: First, 
that before the use of antitoxin 90 per cent, of laryngeal diph- 
theria required operation, under the antitoxin, however, 39.21 
per cent. Second, that the percentage figures have been re- 
versed, formerly 27 per cent, represented the recoveries, now, 
under antitoxin, the mortality. The committee expects still 
better results when antitoxin will be administered earlier and 
in larger doses, and recommends that all cases of laryngeal 
diphtheria, the patient being two years or over, should receive 
as follows: Two thousand units at the earliest possible moment, 
two thousand units after twelve or eighteen hours unless there 
be an improvement, and the same dose twenty-four hours after 
the second dose if there be still no improvement. Patients un- 
der two years should receive one thousand or fifteen hundred 
units. 

Dr. Dillon Brown's personal experience being unusually 



DISEASES OF THE RESPIRATORY ORGANS. 477 

large and carefully recorded, I add without comment the fol- 
lowing figures reported by him. He divided his cases into three 
classes: Previous to November, 1890; from November, 1890, 
to September, 1894 (calomel sublimation period); from Sep- 
tember, 1894, to April 1, 1897 (antitoxin period). Of 442 cases 
of intubation without calomel sublimations and without anti- 
toxin, 27.3 per cent, recovered. Of 295 cases of intubation with 
calomel sublimations, 41.6 per cent.; of 69 cases of intubation 
with antitoxin 67.8 per cent, recovered. Without sublimations, 
10.1 per cent.; with sublimations, 13.2 per cent.; with anti- 
toxin, 23.3 per cent, recovered. During the first year with 
antitoxin there were recoveries after operation in 38.4; during 
the second year, 62.9; during the third, 94.7 per cent. The 
apparently bad results during the first year were probably due 
to two causes: inferior antitoxic serums and insufficient doses. 
Neurotic affections of the larynx of infants (and children) 
are quite frequent, particularly spasm of the glottis, under the 
influence of the inferior laryngeal nerve, which controls both 
the contractors and the dilators of the glottis. The treatment 
is directed by its manifold causes. Indigestion, both chronic 
and acute, is a frequent cause and should be relieved; particu- 
larly in neuropathic families the diet and hygiene of the infant 
are of the utmost importance. Fresh air, cautious exposure to 
cool or cold water, and early addition of liquid animal food to 
mothers milk or to the artificial feeding are of importance. 
Ehachitis, being the most frequent cause of laryngismus stridu- 
lus (p. 143), requires early attention; digestive disorders must 
be corrected, and the general irritability relieved by bromides 
or camphor. Monobr ornate of camphor may be given for weeks 
in daily doses of from one to three grains (0.05-0.2). Emo- 
tional disturbances, which will affect neurotic children at an 
early age, should be avoided. A screaming spell and fright will 
act as proximate causes. The attacks (some beginning with 
apncea, mainly those of laryngismus stridulus) must be 
watched, the baby taken up so as to ease the larynx, the head 



478 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

raised, the tongue (if aspirated and doubled up) drawn forward, 
the throat tickled, water dashed into the face, and chloroform 
inhaled if the local spasm be followed by a general convulsion. 
The influence of the thymus gland was discussed on p. 161. 

Paralysis of the glottis is not so frequent; in the infant quite 
rare, and very rarely congenital. Diphtheria, hysteria, and 
cerebral diseases, also whooping-cough, which should be re- 
lieved as much as possible, may give rise to unilateral or bi- 
lateral paralysis, anaemia may create a predisposition, glandular 
swellings prove a proximate cause. Complete paralysis depend- 
ing on that of both posterior muscles, which contract the glot- 
tis, produces a very severe dyspnoea, which is relieved during 
expiration but cannot be tolerated long. Intubation or trache- 
otomy may be demanded for immediate aid. Otherwise, atten- 
tion to the predisposing causes, reduction or removal of glands, 
and mainly the systematic application of the interrupted cur- 
rent through the breadth of the larynx will offer relief and 
gradual, sometimes rapid, recovery. 

Neoplasms of the infant's or child's larynx are by no means 
rare. Many of them are congenital; mostly so the numerous 
papillomata. Fibromata and enchondromata are also met with, 
and epithelioma has been observed. Sometimes they develop 
their first symptoms after an incidental inflammatory affection. 
The rules for their removal are about the same as in the adult, 
only the latter are more amenable to operations through the 
mouth. Indeed, none but older children can be thus treated. 
A. Rosenberg collected two hundred and thirty-one cases 
of laryngeal papillomata in children {Arch. Laryngol., v.). 
Laryngotomy gave 37 per cent, recoveries. In 38.5 per cent, 
there occurred relapses. Mere tracheotomy was performed in 
34 cases; 4 recovered spontaneously afterwards; endolaryngeal 
treatment after tracheotomy exhibited a permanent cure in 12, 
temporary improvement in 1, and relapses in 3 cases. Exclu- 
sive endolaryngeal treatment gave a complete cure in 50 per 
cent, of children under four years, 70 per cent, between four 



DISEASES OF THE RESPIRATORY ORGANS. 479 

and eight, and 50 per cent, of eight years and older. According 
to these figures, endolaryngeal treatment is preferable unless 
there be a dangerous degree of dyspnoea which could be treated 
with intubation; tracheotomy with subsequent endolaryngeal 
treatment would be the next choice, and laryngotomy would be 
reserved for very serious and unusually urgent cases. Still, it 
appears that the latter will be preferred by all who do not claim 
great specialists skill and have no hospital at their disposal. 
Laryngotomy is performed with or without previous trache- 
otomy, according to surgical rules, exactly as for the extraction 
of foreign bodies. There is one danger more urgent in infants 
and children than in adults; that is hemorrhage, slight or 
copious. Blood flowing down into the narrow air-passages, 
even in small quantities, is liable to result in lobular pneumo- 
nias of a dangerous character. The operation should, there- 
fore, not be performed without a thermocauter or electrocauter 
ready for immediate use. Foreign todies in the larynx should 
be removed through the mouth if possible; if not, by laryn- 
gotomy. In order to facilitate the exit of a foreign body 
from the trachea or the bronchi tracheotomy is demanded, after 
which it is best not to introduce a tube, except temporarily. 
The trachea may then be sewed to the integuments, or may be 
kept open by hooks joined by an elastic band, according to A. 
Caille. 

Congenital stricture of either the larynx or the trachea (rare, 
fortunately) may be mistaken for laryngeal tumor. 

3. The Bronchi. 
Bronchial catarrh, bronchitis, in all its localizations, from the 
windpipes of large size down to the capillaries, requires an 
equable temperature of about 70° F., moist air, and rest in 
bed, though there may be no fever except a slight one towards 
evening. Plenty of water, — no ice, — preferably alkaline mineral 
waters, should be given; older children may be prevailed upon 
to take gum-arabic water, flaxseed tea, or other glutinous decoc- 



480 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tions which, relieve the accompanying pharyngeal irritation. 
Mitigated mustard-plasters (mustard 1, flour 4-8) or embroca- 
tions of turpentine are used to advantage. Underclothing must 
be changed when moist with perspiration. A cotton-batting 
wrapper round the chest (the sheet spread out and two arm- 
holes cut into it) acts favorably both by keeping up a uniform 
temperature and by gently irritating the surface. As a rule, 
it acts better than warm poultices, which are liable to moisten 
the clothing and bedding, and thus add discomfort and the dan- 
ger of a new attack. Where, however, the surface is dry, they 
may be applied, or, better still, in most cases, a sheet of one or 
two thicknesses well wrung out of cool water, wrapped round 
the chest and changed every hour or half-hour after it has got 
hot. Bicarbonate of sodium from ten to fifty grains (0.6-3.0) 
daily, according to age, and an equivalent of a grain of ipecac 
distributed over the day, or (and) from ten to twenty grains 
(0.6-1.5) of ammonium chloride with extract of licorice in 
repeated doses during a day when expectoration is viscid and 
requires liquefying, will answer in most cases. Apomorphia 
one one-hundred-and-twentieth grain (0.0005) every two or 
three hours will act as an expectorant, so will terpine hydrate 
in frequent doses of one-quarter to one-half grain (0.015-0.03), 
particularly in chronic catarrh. Complication with asthma 
and insufficient expectoration is benefited by iodide of potas- 
sium in daily doses of four or fifteen grains (0.25-1.0). Insuffi- 
cient expectoration with general debility demands the car- 
bonate of ammonium (gr. J-l == 0.015-0.06) every half -hour 
or at longer intervals, aq. camphor (one-half to one teaspoonful) 
often, or camphor (gr. J-l = 0.01-0.06) every half-hour to 
every two hours in diluted mucilage. The German preparation 
of liquor ammon. anisatus has been introduced into the Formu- 
lary of the American Pharmaceutical Association; from two to 
six drops may be taken every hour or two hours. Accumulation 
of mucus in the bronchial tubes, with inability to expectorate 
and danger of suffocation, may demand an emetic, and asphyxia 



DISEASES OF THE RESPIRATORY ORGANS. 481 

cold affusion and raising the infant and carrying him about: 
frequent change of position is advisable in every severe case. 
When, in bad cases of capillary bronchitis, cyanosis is on the 
increase, and the voice has not been heard for some time, it 
is absolutely necessary to make the baby cry. Slapping with a 
wet handkerchief, swinging, or closing the nares for a few 
moments, and all the means recommended for the asphyxia of 
the newly-born, are demanded. The interrupted electric cur- 
rent may be used with the rules and restrictions recommended 
above (p. 93). Cough, when irritating and harassing, requires 
narcotics. Small doses of an opiate at regular intervals, or 
(and) a larger one at bedtime, or repeated doses of extr. 
hyoscyam. (grs. 1-1^ = 0.06-0.1 altogether through the day), 
and an opiate for the night, act very beneficially. 

The chronic form of bronchial catarrh demands similar medi- 
cation. Preventive measures are the habitual use of cool or 
cold water and the treatment of such constitutional disorders 
— for instance, rhachitis — as are known to create a predisposi- 
tion. Terpine hydrate, and of terebene ten or twenty drops 
daily, will act well. Chloride of ammonium may be evaporated 
on a hot stove or tin enough to penetrate the whole room (no 
tent required) and inhaled. Turpentine inhaled with steam or 
spread on sponges or towels is also useful. The pneumatic 
treatment (inhalation of compressed air) has been recom- 
mended again by Biedert; it finds its principal indications in 
atelectasis and peribronchitis. The frequent complication with 
pharjmgeal catarrh demands the local treatment of the fauces; a 
mild solution of nitrate of silver (1 : 500) may be used as a spray 
once every day or every two days. TYlien tuberculization is 
feared, the protracted use of cod-liver oil, guaiacol several times 
daily, in two- or four-drop doses (or creosote), together with a 
change of climate, preferably moderate altitudes, are indicated. 

Fibrinous bronchitis is by no means so rare as it was formerly 
reputed to be. Indeed, during epidemics of diphtheria it is 
not uncommon. Still, the pseudo-membranes found in the 

31 



482 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

bronchi are not always of the same nature. While some are 
diphtheritic, others consist of dry and coagulated mucus re- 
sembling the membranes of "enteritis membranosa." In ac- 
cordance with this difference of the prevailing condition, a case 
may last days or months. Antipyretics are still less indicated 
than in the common forms of bronchitis. Mercurial treatment 
like that required in diphtheritic laryngitis of every variety 
(p. 476) is the most reliable internal remedy. Inhalations of 
steam, frequently repeated or kept up constantly in urgent 
cases, inhalations of turpentine with or without steam, of 
chloride of ammonium, often repeated, and fumigations 
through one or two days of from five to fifteen grains (0.3-1.0) 
of calomel (when dyspnoea is urgent, every hour or every few 
hours, under a tent) will act well. The internal use of iodide of 
potassium in daily doses of from ten to fifty (0.6-3.0) grains, 
and in cases of undoubted bacillary diphtheria (p. 253), anti- 
toxin are indicated and useful. 

Bronchial catarrh, croup, and some forms of pneumonia are 
proximate causes of a collapse of pulmonary tissue, atelectasis, 
the congenital and postnatal varieties of which have, been 
treated of before (p. 94). The predisposing causes are general 
atrophy with its muscular debility, and rhachitis through its 
narrowing the shape of the thorax. In this condition, replete 
as it is with imminent danger, the baby must be carried about, 
the posture in bed must be changed frequently, he must be 
made to cry, electricity should be used, and, besides an occa- 
sional emetic, stimulants such as alcohol, camphor, ammonium 
carbonate, and musk should be employed frequently and copi- 
ously. 

The nature and symptoms of asthma do not differ from those 
of the same affection in adults; nor does the treatment. Swell- 
ing of the mediastinal glands, and hypertrophy of the tonsils, 
flatulency which impedes the free movements of the diaphragm 
("asthma dyspepticum"), peribronchitis, emphysema, which is 
by no means rare, and nasal reflexes are the main causes, and 



DISEASES OF THE RESPIRATORY ORGANS. 483 

should be attended to. In the latter class of cases brushing 
the mucous membranes of the nose and pharynx with a cocaine 
solution of from two to ten per cent., or the use of cocaine 
spray, may, in appropriate cases, relieve an attack; the cauteri- 
zation (actual, or chromic acid) of the hypertrophied tissue and 
the removal of a polypus may occasionally be the only things 
required for an actual cure. Unfortunately, this class of cases 
is not so numerous as it was believed to be a number of years 
ago. Those depending on peribronchitis and emphysema are 
more frequent. In them the protracted use of three daily doses 
of from two to five grains (0.125-0.3) of potassium iodide, to- 
gether with a sufficient bedtime dose of chloral or of an opiate 
to meet the night attack, will have favorable results. Tincture 
of lobelia, two or three drachms (8-12 cubic centimetres), fluid 
extract of quebracho or of grindelia, one or two drachms (4-8 
cubic centimetres) daily, will often have a beneficial effect in 
distressing dyspnoea. The inhalation of stramonium, of nitrate 
of potassium paper, or of pyridin vapors is often resorted to; 
unfortunately, with so little permanent result as to give any 
number of proprietary medicines and nostrums a large field of 
activity. The treatment of enlargement of mediastinal glands, 
of tonsils, and of flatulency was discussed in other chapters. 

The periodic night cough, described as a special variety in 
some of the books, is either a mild attack of asthma or is 
pharyngeal or tubercular; most pharyngeal coughs, however, 
are met with in the morning, after waking up. These noc- 
turnal attacks may be obviated by a drink of alkaline water at 
bedtime, to be repeated at every waking up, and by a dose of a 
bromide, or of chloral, or of an opiate at bedtime, and by atten- 
tion to indigestion and constipation. Quinine is useless. 

4. The Lungs. 
Pneumonia. — There are three anatomical varieties of pneu- 
monia in infancy and childhood: the catarrhal or lobular, the 
fibrinous or lobar, and the interstitial. Nearly two-thirds of 



484 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

the cases belong to the first, one-third to the second, and a 
limited number to the third class. Not one of them, how- 
ever, is always found pure and uncomplicated. Indeed, com- 
plications of the lobular with the lobar, of either of them with 
the interstitial, and possibly of each of the three with pleu- 
risy, are quite numerous. The lobular form is almost always, 
the lobar quite frequently, preceded by bronchial catarrh, 
which has its well-understood sources in previous attacks, in 
exposure, sudden changes of temperature, local irritation by 
foreign bodies, rhachitical or tubercular mediastinal and bron- 
chial glands, diphtheria, measles, influenza, typhoid fever, 
whooping-cough, etc. Thus, the preventive treatment of pneu- 
monia has its positive and distinct indications. Nasal catarrh 
is never so slight as not, possibly, to endanger the lungs. Rha- 
chitis, glandular tuberculosis, measles, and whooping-cough 
must not be left alone to find their slow road to their legitimate 
termination for better or for worse. Every child, while well, 
should be armed against the results of exposure by regular in- 
vigorating ablutions and frictions with cold water, and when 
exposure has taken place and the consequent fever made its 
appearance, a warm bath, acetate of ammonia, camphorated 
tincture of opium, tincture of aconite, hot drinks, salicylate of 
sodium, or another one of the antipyretics and diaphoretics, 
with uniform temperature and rest in bed, may be the means 
of preventing pneumonia. 

The treatment of pneumonia is not yet influenced by modern 
views on etiology. The attempts at procuring immunity in 
animals by the blood-serum of pneumonic patients, thus es- 
tablishing a serumtherapy, may prove more successful, when 
more will be known. The large number of microbes which are 
found in pneumonia, pneumocoecus, diplococcus lanceolatus, 
streptococcus and staphylococcus, and others, do not yet justify 
the abrogation of pneumonia as an inflammatory process, and 
the claim that it is only a process of germ-culture in which the 
air-cells act as culture-tubes and the functional circulation as a 



DISEASES OF THE RESPIRATORY ORGANS. 485 

culture medium, while the nutrient circulation maintains the 
integrity of structure without taking an essential part in the 
pneumonic process. Lungs of children who did not die of 
pneumonia, also those of recently killed domestic animals 
(Diirck in D. Arch. Min. Med., 1897, vol. lviii.), contained the 
diplococcus pneumoniae and the mixture of bacteria met with 
in pneumonia. Pure cultures of bacteria blown into healthy 
lungs gave Diirck no pneumonia, irritant dust did; so did cul- 
tures and dust mixed. Here, as almost everywhere in bacteric 
etiology, it is not the presence of ever so many ever so virulent 
microbes, but their fixation and their ability to generate toxins 
which deserve credit for morbid tissue changes. 

Acute lobular pneumonia is less a systemic disease than is the 
lobar form; its direct and immediate influence on the nervous 
and muscular, inclusive of the cardiac, systems is less marked; 
it is not so frequently complicated with pleurisy. Thus, there 
is less danger at first in lobular pneumonia; there is more at a 
later period, because its duration is liable to be so long as to 
make the prognosis uncertain. The danger may come from 
the heart, but it mainly lies in suffocation, which depends less 
on the extent of inflammatory exudation than on collateral 
congestion and oedema. 

Interstitial pneumonia runs the most protracted course. 
Fever is liable to be high and prolonged over weeks and 
months; recovery is but rarely complete, induration and re- 
traction of the pulmonary tissue, with bronchiectasis, being 
quite common. 

Thus, it becomes evident that no uniform course of treat- 
ment can be dictated either for all forms of pneumonia or for 
all cases. The former are several, the latter are individual. 
After all, the patient is to be treated, and not the Greek name 
of his disease. Still, there are certain rules which ought to be 
enforced in every case. 

Insist upon absolute rest of body and mind, exclude visitors, 
light, and noise. 



486 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Keep the temperature of the room between 68° and 72° F. 
and the air moderately moist. 

Let the patient select his own position. 

Isolate a lobar case. 

Give liquid food, and plenty of water, or lemonade, or hy- 
drochloric acid and water. 

Believe the circulation from accessory incumbrances; a dose 
of calomel will facilitate the action of the diaphragm by empty- 
ing the bowels and relieving flatulency, and will diminish the 
tension of the arteries. 

The main dangers in acute pneumonia are: high tempera- 
ture, heart-failure, and suffocation, which may result from the 
condition either of the lungs, or of the right heart (the left 
not being at fault so often as it is in the adult), or of both; also 
complications like that with nephritis, which is either a coinci- 
dent or the result of toxic (pneumococcic ?) infection. 

Which degrees of temperature may be allowed to last, and 
which are to be interfered with? Is it 103°, 104°, 105° F.? 
It is well understood that persistent high temperature disinte- 
grates tissue, but this effect is not equally observed in all 
cases. Many a child bears 104° quite easily, while others 
succumb to 103°. Moreover, a temperature which is badly 
borne the first day or two appears to be an indifferent matter 
afterwards. Thus, an antipyretic treatment may be indicated at 
first and be no longer required later, particularly in those cases 
which exhibit a decided morning remission; for it is mainly 
a persistent height of temperature that is injurious, not its 
occasional, though regular, rise. That is why, for instance, 
relapsing fever, with its enormous temperatures but complete 
and long intermissions, has only a small mortality. 

The custom of depressing temperatures in all cases which ex- 
hibit a temperature of 103° F., or thereabouts, is bad; it is not 
the temperature that is injurious, but the absence or insuffi- 
ciency of resistance that the tissues offer to its action. To 
lower temperature we have er number of remedies. The latest 



DISEASES OF THE RESPIRATORY ORGANS. 487 

additions to our antipyretic treasures are very well known and 
too universally employed. Phenacetin, antipyrin, and ace- 
tanilide have more frequently lowered temperatures than they 
have saved lives. Their doses, uses, and dangers are well un- 
derstood by all practitioners. Wherever they are found in- 
competent, their combination with quinine has proved more 
effective. The latter, by itself, is, however, no longer the sine 
qua non which it was formerly believed to be. In all cases 
with marked remission it acts well, but it is during the re- 
mission only that it should be given. Half a gramme to a 
gramme (grs. 8-15) may be thus employed. It may be used 
internally or hypodermically. Now and then injections into 
the rectum, or suppositories, are required or advisable when the 
stomach cannot be relied upon. The preparation to be used in 
the rectum must be one of those which are most soluble: the 
bisulphate, muriate, bromide, or carbamide. No acid should 
enter into the solution; large quantities of glycerin are objec- 
tionable. The rectal dose should be at least fifty per cent, 
larger than that employed internally. 

The internal administration is often hindered by the taste 
of the drug. Thirty parts of the compound known as elixir 
simplex cover the taste of one part of the sulphate, provided 
the mixture is made with each dose and not kept ready; thus, 
the drug should be prescribed in the form of a powder, to be 
mixed with the elixir when needed. Preparations of coffee, 
either infusion or syrup, hide the taste of quinine quite well; 
so does, to a certain extent, licorice extract; so does choco- 
late. The neutral tannate of quinine is tasteless, but the dose 
should be two and a half times larger than that of the sulphate. 
The muriate agrees best with an irritable stomach, the bromide 
with an impressible brain. The latter is slower in producing 
cinchonism. The best preparation for hypodermic injections 
is the carbamide of quinine, which dissolves easily in four or 
five parts of water, remains in solution, and yields no deposits 
of quinine in the subcutaneous tissue. I have employed it for 



±88 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

at least a dozen years, and observed serious local irritation in 
but one instance. 

The best antipyretic is cold. Its use has been praised and 
condemned, as everything deserves to be that is employed 
either properly or thoughtlessly. Most cases will do quite well 
with sponging, or with friction by means of wet and cold 
towels. The latter plan acts both as a refrigerant and a stimu- 
lant. Cold bathing was once eulogized immensely, then ab- 
horred and warm bathing substituted. The rationale of cold 
bathing is the cooling of the surface (that is, of fourteen 
square feet in the adult; more than proportionately that in the 
young) with its immense surface circulation. So long as this 
circulation continues active, new blood will come to the surface 
every moment, and the whole body is thereby cooled. TVhen 
it is no longer active, the heart weak, and the extremities cold, 
cold bathing is dangerous. The rule I have always followed 
is this: no cold bath for cold extremities: no more cold bathing 
when once, after it, the extremities remain cold or cool. In 
these cases after a cold bath the surface becomes colder than 
before, it is true; the interior, however, warmer than it was. 
I have reported the case of a little child, twenty years ago, who 
was the first to teach me that lesson. A few cold baths had 
reduced his temperature and his tendency to convulsions. 
Then another seemed to be indicated. It appeared to render the 
required service, but the baby became convulsed. The temper- 
ature in the rectum had risen from 104| o to 106° F. A hot 
bath, instantly given, restored the external circulation, and ten 
minutes afterwards the rectal temperature was below 102°. 

A great promoter of circulation, and thereby of radiation 
from the skin, is surface warmth, and particularly warm ex- 
tremities. "Warming-pans ought always to be applied to the 
feet and legs when cold is to be employed on the rest of the 
body. In place of cold bathing, I have mostly employed cold 
packing from the chest down to the thighs, the arms usually 
outside the pack. Xothing is easier than to wrap a baby up in 



DISEASES OF THE RESPIRATORY ORGANS. 489 

a single wet towel, which is covered by a small blanket; in an 
urgent case it should be replaced by another one (spread out 
beforehand) every two or five minutes. From twenty to forty 
minutes' packing will reduce the temperature from 106° to 
101° F., and below. In many instances the rapidly falling 
temperature demands artificial warming immediately after- 
wards. When the frequent changing of the pack is undesirable, 
the cloth may be allowed to remain, and is frequently cooled 
by rubbing a piece of ice over the whole surface. If water col- 
lect under the patient, it can easily be absorbed by towels or 
sponges. A temperature of 108° in a baby of four months, 
suffering from pneumonia, was reduced to 104° in twenty- 
five minutes; after that it sank rapidly to 94J°, and artificial 
warming of the surface was required. 

From what has been said it is evident that very feeble and 
anaemic babies do not tolerate cold, though their temperature 
be ever so high; in such cases a warm bath, or tepid packs 
either with water or alcohol and water, or a warm bath gradu- 
ally and gently cooled down while the little body is constantly 
being rubbed, should take the place of the cold pack; or 
cold applications to a part, perhaps the anterior aspect of the 
chest, are found to suffice. They both reduce temperature and 
relieve local pain. In many cases a light ice-bag over the 
heart acts both as a refrigerant and a stimulus to the organ at 
the same time. 

The acceptance of these views I urgently recommend to those 
to whom they are in part new. Before and after 1870, when I 
recommended {New York Medical Record) cold water in typhoid 
fever, scarlatina, variola, ophthalmia, diphtheritic conjuncti- 
vitis, diphtheria, lobar and other pneumonia, heart-disease, 
local inflammations, phlegmon, synovitis, and peritonitis, I 
had ample opportunities to test what I am here advocating. 
Those who want to inform themselves thoroughly on matters 
connected with this subject I refer to Dr. Simon Baruch's well- 
known book, and other writings. 



490 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

The heart furnishes urgent indications for treatment in 
many cases of pneumonia. When in a healthy condition, its 
innervation and force are not easily disturbed; still, every pul- 
monary disease taxes its powers. Lobar pneumonia requires 
cardiac stimulation at an earlier period than the lobular kind. 
There is none, however, but demands it at some time or other. 
That being the case, I earnestly advise not to wait, for heart- 
failure is more easily prevented than cured. Be our treatment 
ever so expectant, it must not be indolent and indifferent. In 
order to correct the faulty pulmonary circulation the heart 
should be stimulated at an early period. But how? 

Alcoholic beverages are employed for this purpose by many, 
for alcohol is certainly a cardiac stimulant; it is believed by 
many to lower arterial tension, — a function which is doubtful, 
at least in pure inflammatory disorders; moreover, it is believed 
to be an article of food. In the small quantities in which it 
is administered it certainly is not. Much of it is eliminated 
unaltered through the lungs, which are thus burdened with 
that additional labor while in a condition of congestion and 
incompetency. Besides, kidney complications, which are not 
rare in pneumonia, and brain affections, which are frequent, 
particularly in small children, contraindicate the use of alco- 
hol. I dare say that the pneumonia of a fairly developed in- 
fant or child contraindicates rather than demands the adminis- 
tration of alcohol at an early period of the disease. Later, 
when the conditions change, alcohol may be required in large 
doses, always, however, much diluted. A recent writer has 
indeed proclaimed that the doses of alcohol given by medical 
men in the diseases of children are in direct proportion to their 
ignorance, but epigrammatic pronunciamentos do not yet re- 
move alcoholics from among the stimulants. 

Digitalis stimulates and contracts the heart, but also the 
arteries, both the largest and the very smallest, and thereby 
increases the peripheral resistance. A few large doses may 
restore the equilibrium of the faltering circulation, and should 



DISEASES OF THE RESPIRATORY ORGANS. 491 

then be stopped. I have not infrequently given the equivalent 
of from one to four grains of digitalis (0.06-0.25) in a single 
dose, which was repeated once or more times. This mode of 
administration insures all the coveted effect on the heart and 
pulse without any irregularity, and gives both a result in a few 
hours and the indication to cease, while the usual small doses 
exhibit their action after days only. ^Ye may afterwards con- 
tinue its use in small doses, either alone or in combination with 
strophanthus, sparteine, or caffeine, all of which have no such 
disagreeable effect on arterial tension as digitalis; or we may 
give them without digitalis. To give doses of tincture of 
strophanthus of less than a drop, or sparteine sulphate of less 
than one-quarter or one-eighth of a grain, every hour or two, is 
useless. Such effect as we require we have a right to demand 
speedily, and the doses should be large enough to enforce it. 

Whenever the peripheral circulation becomes insufficient, 
with small pulse, digitalis alone must not be continued; it 
should be combined with nitroglycerin or sodium nitrite, the 
former in hourly or bihourly doses of from one five-hundredth 
to one one-hundredth of a grain, the latter in doses of from 
one-tenth to one-quarter, or these remedies may be given alone 
until the pulse is revived. They are principally required when 
the feebleness of the heart is mainly perceptible in the right 
ventricle. There are cases of pneumonia in which the arterial 
pulse is good, but the external veins large, the nails blue, the 
skin cyanotic, with great dyspnoea and pulmonary oedema, to- 
gether with perspiration, increased cardiac dulness, enlarged 
liver, intestinal oversecretion, and albuminuria, — symptoms 
which point directly to incompetency of the right ventricle. 
In these cases the external circulation must be restored at once, 
and the nitrites will contribute to fulfilling that indication. 
So will diuretin in doses of from two to ten grains (0.125-0.6) 
administered from three to five times a day. Besides, local 
depletion by leeching will sometimes do good. In the adult we 
should open a vein; a child of advanced age may also be saved 



492 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

in this way. Once, and once only, when I was younger than I 
am to-day and more courageous or less cowardly, I opened the 
engorged jugular vein of a young child suffocating from pneu- 
monia. The tenement-house people for whom I did it thought 
it the proper thing and nothing else, while I was not quite so 
confident: the child got well. Cupping, both dry and some- 
times wet, large sinapisms, and mustard baths will serve a good 
purpose. Concerning the latter method, Dr. L. Weber pub- 
lished an elaborate article some fourteen years ago. "General 
mustard bathing I have now and then resorted to in severe 
inflammations of the lungs, as well as in those of the brain. 
I prepared a hot bath and threw mustard into it ad libitum 
in order to produce a very powerful derivation to the skin 
in a very few minutes, and I think it had most beneficial re- 
sults."* It is in these cases also that the inhalation of oxygen 
(better through the nose than the mouth) and artificial respi- 
ration will contribute a great deal towards saving time and 
life. 

The distressing cases of catarrhal pneumonia engrafted upon 
the extensive bronchial catarrh or capillary bronchitis of the 
very young will sometimes get well only after we shall have 
succeeded in making them cry, together with artificial respira- 
tion, inviting the respiratory muscles to reflex efforts by dash- 
ing cold water on them, using for brief moments the inter- 
rupted current, etc. 

Direct stimulation of the heart may require the use of 
strychnine in small and frequent doses (a baby of one year not 
often more than a thirtieth of a grain — two milligrammes 
during twenty-four hours), and carbonate of ammonium one- 
half of a grain or a grain (0.03-0.06) in anise-seed water or in 
milk every half, one, or two hours. In cases of urgent neces- 
sity the stimulants should be used subcutaneously, the sulphate 
of strychnine in repeated doses of one one-hundredth grain at 

* Jacobi, in New York Medical Record, August 15, 1870. 



DISEASES OF THE RESPIRATORY ORGANS. 493 

least, the salicylate (or benzoate) of sodium and caffeine in 
doses of from one to five grains (equivalent to one-half of that 
amount in caffeine) every one or four hours; camphor will 
serve the same purpose. Its solutions in alcohol or ether are 
quite painful. I always employ it in four or five parts of sweet 
almond oil; of this I inject from six to twenty drops, according 
to indications; very slowly, because it passes through a fine 
needle with more difficulty than does a watery solution. 

In connection with these remarks we are enabled to judge 
of the claims of the routine treatment with strychnine, digi- 
taline, and aconitine which was imported a few years ago. It 
is easily perceived that it finds its indications like a ready-made 
coat which fits many, but not all, and would not be worn unless 
first tried on. But, a coat is not so easily believed to fit every- 
body as is a newly eulogized treatment. 

When, during hepatization and the period of incipient reso- 
lution, expectoration is insufficient, the remedy is inhalation of 
steam, with or without turpentine. The latter may be spread 
through the room by means of large sponges, or on towels 
which are soaked with it, or it may be evaporated on boiling 
water. The easiest way is to fill the whole room with the vapor. 
Inhalers are insufficient and annoying. Give camphor, aqua 
camphorse in teaspoonful doses or more, or one-quarter- to one- 
grain doses in diluted mucilage, or benzoic acid powders in the 
same doses, or ammonium carbonate. Ipecac may derange the 
stomach, senega is either an adjuvant or a placebo. Drinking 
of plenty of water, mainly alkaline waters, — Seltzer, Vichy, 
Poland, — also doses of bicarbonate of sodium or iodide of potas- 
sium, will increase and liquefy the bronchial secretion. Am- 
monium chloride is of but little use in hepatization; but 
evaporated in amounts of ten or twenty grains every few hours 
on a hot stove or over a flame, it fills the room with a white 
cloud which greatly stimulates the bronchi. Warm poultices 
will serve the same purpose. Their place is .during hepatiza- 
tion for the purpose of aiding absorption, not in the first stage 



494 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

of pneumonia. When nursing is insufficient, and there is dan- 
ger of wetting the clothing and bedding, it is best to substitute 
for them a cotton-wadding jacket, covered or not with oil silk 
or, better, flannel, which protects against exposure and keeps 
up a uniform temperature of the skin. 

Pleural pain is relieved by gently strapping the chest, when 
tolerated, — it mostly is, — by sinapisms, which must be kept on 
a few minutes only and repeated from time to time; warm 
poultices; a few doses of sodium salicylate or phenacetin; in 
urgent cases by a subcutaneous injection of morphine. Vesica- 
tories are injurious; they chafe, irritate, and annoy. Their only 
— rare — indication is in the long persistence of hepatization, 
with or without chronic pleurisy. 

Irritating, hacking cough demands small doses of opium. 
Much of this cough is pharyngeal, and is relieved by frequent 
drinking of small quantities of water. Sleeplessness and great 
general irritation demand a dose of opium for the night. A 
sleep of an hour or two affords great relief to the cough and 
to all the symptoms. As a general rule, however, the habit of 
giving opium in the first stage of pneumonia is a bad one. Rest 
should not be bought with death. 

The bad odor of complicating gangrene demands inhalations 
of turpentine, eucalyptol, or carbolic acid; the presence of ab- 
scesses in the lung demands surgical interference, unless there 
be a spontaneous rupture through a bronchus. Most abscesses 
are within reach of the knife and actual cautery, for generally 
there is a sufficient amount of pleural adhesion to render access 
devoid of much danger. 

Complication with malaria, which is rare, requires quinine; 
intermittent pneumonia, which is also uncommon, quinine and 
ergot; complication with nephritis contraindicates digitalis 
and alcohol, and suggests the substitution therefor of sparteine, 
camphor, and nitroglycerin; in atelectasis the stronger stimu- 
lants are required, and artificial respiration by the different 
methods; the patient should be made to cry; cerebral disease, 



DISEASES OF THE RESPIRATORY ORGANS. 495 

while acute, indicates ice and purgatives, and bromides; when 
chronic, iodide of potassium. 

Hypostasis and hypostatic pneumonia, so common in infec- 
tious diseases and in conditions of great debility, require fre- 
quent changing of position from one side to the other and the 
early administration of stimulants in large doses, together with 
friction of the entire surface with cold or hot water, or with 
alcohol and water. The most powerful of all internal stimu- 
lants — Siberian musk — should be given frequently, — viz., every 
half to one or two hours, — in doses of from one-half to two 
grains, until from six to fifteen grains (0.4-1.0) have been 
taken in the course of half a day. 

Interstitial pneumonia is treated on the general principles 
laid down before. Later, iodide of potassium in sufficient doses, 
a mild tincture of iodine externally, and an occasional vesica- 
tory. When it has become chronic, digitalis may be given for 
months in small doses to keep up both a sufficient circulation 
through the indurated lung and a competent nutrition of the 
heart muscle, and iodide of potassium alternating with iodide 
of iron. Persistent and careful pulmonary gymnastics should 
be continued for years. 

Emphysema of the infant lungs, sometimes not easily diag- 
nosticated because of the size of the liver and of abdominal 
tympanites, and never unless percussion be performed very, 
very gently, is often overcome by the elasticity of the pul- 
monary tissue, and therefore its prognosis, no matter whether 
produced by forced inspiration (in pneumonia) or by forced ex- 
piration (severe attacks of coughing), or even that rare form 
which results from ill nutrition of the alveoli, is not so bad as it 
mostly is in adults. Its treatment is that of chronic catarrh, 
and by gymnastic exercise of the respiratory muscles and gen- 
eral roboration. Besides, forcible expiration ought to be prac- 
tised extensively; during expiration the chest wall ought to be 
well compressed. Snuff should be used half a dozen times daily, 
and copious sneezing procured. Expiration into the rarefied 



496 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

air of one of the many pneumatic apparatuses is also recom- 
mended. It may be tried on tractable children. 

Pulmonary cedema requires the causal treatment of its origin, 
which can be traced to cardiac, pulmonary, or renal disease. 
Urgent cases — for the disease may prove fatal in a short time — 
require dry cupping, now and then the emptying of the lungs 
by an emetic (apomorphine subcutaneously when vitality is low 
and the expelling muscles are unable to act), and stimulation 
of the excreting organs and of the heart. A powerful purga- 
tive — calomel, croton oil, or elaterium — is an active derivant. 
Digitalis in large doses (a few minims of the fluid extract at 
once) will stimulate the heart. The salicylate or benzoate of 
sodio-cafreine in subcutaneous injections, one to five grains 
(0.05-0.3), repeated five or six times at intervals of fifteen min- 
utes, acts beautifully. Acetate of lead stops oversecretion in a 
good many instances. Pilocarpine (one-twentieth to one-sixth 
grain) subcutaneously has relieved, and saved, many a case re- 
sulting from renal disease. 

Pulmonary hemorrhage is not frequent, for tuberculosis of the 
young lung produces induration and vascular obstruction 
rather than cavities; and though whooping-cough gives rise 
to hemorrhages, they are tracheal and bronchial rather than 
pulmonary. Cardiac diseases may lead to venous obstruction 
and thereby to hemorrhages. Digitalis, lead, alum, ergot, nar- 
cotics, mainly opiates in quieting doses, and ice temporarily to 
the chest, with a hot (mustard) bath of the lower half of the 
body, as well as absolute physical and mental rest, are indicated. 
Demelin collected twenty-two cases occurring in the newly- 
born (Rev. Obst. Internat., January 1, 1897). They were either 
speedily fatal, or gave rise to alleged melaena (blood swallowed). 

Infarction, with its sudden onset and vehement dyspncea 
(sometimes chill), is the result of embolism, in the newly-born, 
from the umbilical vein or the ductus arteriosus; later, from 
a marantic thrombosis of the sinus, the renal, femoral, or portal 
vein, or from caries of the petrous or some other bone; from 



DISEASES OF THE RESPIRATORY ORGANS. 497 

valvular disease, from an infectious malady, or from an ex- 
tensive burn. The causal indications must be obeyed, if possi- 
ble. Ice applications to the affected part, opiates and digitalis, 
and stimulants when required, symptomatic treatment after- 
wards (antipyretics). 

Some of the cases are followed by gangrene. This condition, 
however, generally results from the presence of foreign bodies, 
from acute infectious diseases, — diphtheria, measles, noma, 
typhoid, — or from (mostly lobular) pneumonia. A few cases 
are also on record as having resulted from careless pneumatic 
treatment. Mineral acids largely diluted with water, as also 
quinine and lead, have been copiously used. Besides stimulants 
given to the required extent, I have relied mainly on inhala- 
tions of turpentine, either from a paper bag in which a sponge 
was kept soaked, or from a kettle with boiling water, or of 
terebene; internally, of terebene, from twenty to fifty drops 
daily, or creosote a few drops daily. 

Such pseudoplasms as have been or may be observed in the 
young lungs demand treatment on general principles. Carci- 
noma has been noticed a few times, also in the mediastinum. 
Sarcoma is more common, mostly in the pleura. The treatment 
should consist in increasing doses of arsenic, and in the injec- 
tion, according to Coley, of the toxin of the coccus erysipela- 
tos and bacillus prodigiosus. Ecliinococcus of the lungs and 
pleura (fluid without albumin and sodium chloride, and with 
scolices) demands free incision, resection of a rib, and drainage. 
Puncture and the injection of Lugol's iodine solution do not 
suffice. Actinomycosis has been reported by Soltmann; the 
case occurred in the posterior mediastinum of a boy of six years. 

Hernia of the lungs has been observed below the clavicle and 
on the back. The soft elastic tumor changes its size with res- 
piration. In such cases the lung is either normal or emphy- 
sematous. The cough disappears after the application of proper 
bandages. Deformities of the chest wall, with or without a 
defect in bones or muscles, particularly the funnel chest, in 

32 



498 THEBAPEUTICS OF INFANCY AND CHILDHOOD. 

which the lower part of the sternum is so drawn in as to 
almost touch the vertebral column, can never be removed, but 
the consecutive contraction of the intrathoracic space can be 
partially counterbalanced by systematic gymnastics and func- 
tional improvement of the lungs at an early age. 

5. The Intrathoracic Lymph-Bodies. 
In close connection with the congestive and inflammatory 
diseases of the thoracic organs are many changes in the bron- 
chial and mediastinal lymph-bodies which can more easily be 
prevented than cured. A protracted catarrh of the bronchi 
results in glandular hyperemia and hyperplasia; a nasal ca- 
tarrh of the newly-born and the nursling descends rapidly with 
the same effect, or the consecutive glandular tumefactions of 
the submental and submaxillary regions implicate the adjoining 
tiers of lymph-bodies; rhachitis, scrofula, and tuberculosis are 
also causes of bronchial and mediastinal adenitis. Bacilli may 
reach the lymph-bodies though the mucous membrane of the 
bronchi though its epithelium be intact. Pressure on veins and 
nerves, also on the trachea; attacks of coughing without crow- 
ing inspiration; fremitus, feeble or increased; respiration, in- 
creased and bronchial, or feeble; dulness over the sternum 
down to the second rib, but not extending to the exterior mar- 
gin of the lungs; dulness posteriorly about the hilus of the 
lungs, more marked to the left than to the right (location 
of thoracic duct on the left), are among the principal symp- 
toms. Pressure on the trachea, or on one of the large bronchi, 
may be such as to cause an actual stenosis and suffocation. 
Fever, if present, depends on complications or on absorption 
from the glands while undergoing changes. Antirhachitical, 
antiscrofulous, and antitubercular treatment are the indica- 
tions. Mercurial ointment, iodide of potassium ointment, in- 
unction of green soap, iodide of potassium internally, iodide of 
iron, increasing doses of arsenic, ice externally if there be any 
local pain, and the treatment of sequela? or complications (ca- 



DISEASES OF THE RESPIEATOEY ORGANS. 499 

tarrh, lobular pneumonia, dyspnoea, protracted fever) are de- 
manded, but will not always prove successful. 

6. The Pleura. 
Pleurisy is of frequent occurrence during the first decade of 
life; empyema is, indeed, more common during infancy and 
childhood than in advanced age. The majority of cases of 
pleurisy which occur in the newly-born are of pyaemic origin, 
and depend mostly on umbilical phlebitis; still, cases with 
serous, and the usual forms of purulent, secretion are not un- 
common in the very young. Pleuritis may be the direct result 
of exposure ("cold"), of contusion, of broncho- and fibrinous 
pneumonia, or of pericarditis and peritonitis. It frequently 
accompanies pulmonary tuberculosis, diphtheria, acute rheu- 
matism, and eruptive fevers. Thus, there is but rarely a causal 
indication for treatment; prevention is best secured by giving 
the utmost care to the management of those diseases which 
cause its outbreak. Its symptoms are often deceptive, for even 
pain is not always present, though it is one of the most frequent 
occurrences. The pain is sometimes quite local; at other times, 
however, it extends over a large surface. Its locality does not 
always correspond with the seat of the pleuritis. The exten- 
sion of the peripherous ramifications of the intercostal nerves 
is so great that the children often complain bitterly of epigas- 
tric pain down fo the umbilicus on the affected side. The 
disease requires absolute rest and immobilization of the chest. 
Broad strips of the usual varieties of adhesive plaster, which 
irritate the surface and render local applications difficult, I 
have discarded long ago. A broad bandage or a moderate-sized 
towel fastened round the chest with safety-pins is more appro- 
priate and is well tolerated. An ice-bag applied to the diseased 
region will often render the best service; it must not come in 
contact with the bare skin. "Where no bandaging is required, 
a cloth well wrung out of cold water, of the size of half a square 
foot, more or less, or surrounding the whole chest, may be ap- 



500 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

plied every fifteen or thirty minutes. It should be covered 
with rubber cloth and flannel. In very bad cases the pain 
should be relieved by a subcutaneous injection of morphine; 
its internal administration is generally useless and sometimes 
hurtful. Local depletion by cups or leeches, I am glad to say, 
I have shunned these twenty-five years; dry cupping may re- 
lieve such children as are old enough and intelligent enough 
not to get excited and not to harm themselves by screaming 
and active resistance. Mustard plasters must not remain longer 
than a few minutes, and may be repeated every few hours. 
Warm fomentations will relieve anaemic and feeble children; 
if possible, they ought to be avoided in the beginning of the 
disease, when the indication to limit congestion and secretion 
is paramount. A dose of calomel sufficient to relieve the bowels 
(sometimes with an opiate) and the use of salicylate of sodium 
in doses adapted to the age of the patient are the remedies 
which will bring relief. The salicylic acid in the latter is not 
present in sufficient doses to lower blood-pressure to an uncom- 
fortable degree. Vesicatories are still less indicated in the first 
stage of pleurisy than later on; they irritate both the skin and 
the patient, cause sleepless nights, and add to the discomfort 
of the occasion, and discomfort and sleeplessness impair the 
prognosis. If there were a benefit to be derived from blister- 
ing, the condition of the pleura might be improved, perhaps, 
but the sick injured, probably. 

If the temperature be so high as to injure the patient, anti- 
pyretics should be given. Probably from three to ten grains 
of quinine administered before noon will lower the afternoon 
rise. If required, a dose of phenacetin, with or without a 
moderate dose of codeine, may be given at eight or ten o'clock 
at night. 

When the fever decreases, or when the heart begins to get 
weak previously, digitalis, strophanthus, sparteine, or caffeine, 
with or without ammonium carbonate or camphor, are indi- 
cated; no improvement, either through diaphoresis or through 



DISEASES OF THE RESPIRATORY ORGANS. 501 

diuresis, need be expected so long as the heart remains weak. 
The choice between the caffeine preparations is a matter of 
indifference. The salicylic acid in the double salt (Na + 
Caffein) is not sufficient to lower the heart's action. At the 
same time an acetate, or a citrate, or an iodide may be given. 
Pilocarpine, which has been recommended, is a two-bladed 
sword, and requires a stronger constitution than almost any 
baby and most children can boast of; in pleurisy there is no 
vital indication that can be fulfilled by pilocarpine to such ad- 
vantage as may be derived from it in certain cases of acute 
pulmonary or intracranial oedema. Externally, at this period, 
tincture of iodine diluted with alcohol may do some little good, 
particularly in cases of "dry pleurisy." It is this form mainly 
which will be benefited by warm fomentations and the use of 
iodides. When the main indication is to absorb effusion, absti- 
nence from drinking, and the use, in fair doses, of table salt, 
which increases diuresis, will be found useful. Diuretin, in 
four daily doses of from two to five grains (0.125-0.3) or more, 
may stimulate the action of the kidneys to such an extent as 
to result in the absorption of the pleural effusion. 

The indications for operative interference with the pressure 
of pleural effusions, no matter of what description, are various. 
It is demanded when the difficulties of either respiration or cir- 
culation, or both, require immediate relief. The latter may 
suffer even without the participation to a great extent of the 
former. Indeed, Trousseau describes a case of fatal collapse 
due to nothing but disordered circulation. Among the symp- 
toms urging the operation are intense dyspnoea, cyanosis, dim- 
inution of renal secretion, anasarca and ascites, and a con- 
siderable dislocation of the heart or the liver. In many cases 
the intercostal interstices are no longer visible, either on in- 
spiration or expiration; they are even found bulging. Not in 
every case are the consecutive disorders proportionate to the 
amount of effusion; indeed, this may be small compared with 
its effects when the pleurisy is complicated or secondary to a 



502 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

disease of either heart or kidneys, or both. Still, the quantity of 
fluid contained in the pleural cavity is more frequently under- 
estimated than the reverse, no matter whether the healthy lung 
is pressed upward and is floating on the liquid in a compressed 
condition, or whether, congested or inflamed, it is swimming 
in the midst of the fluid or adheres in places to the chest wall. 
Thus it is impossible to exactly gauge the indications of the 
operation according to the amount of effusion. Potain's claim, 
that when the latter reaches the level of the clavicle the opera- 
tion should be performed, is justified by the fact that the con- 
secutive symptoms in most such cases are very urgent. In 
most cases we should not wait quite so long. In such per- 
sons as do not subjectively complain, indifference is mostly 
due to lack of cerebral perception, — in conditions of uncon- 
sciousness during meningitis, typhoid fever, or idiocy. When 
the dulness extends high up both anteriorly and posteriorly, 
and no absorption takes place within a few weeks, the opera- 
tion is required. The longer the compression of the lung has 
lasted the smaller will be the chances of its reinflation. It is 
true, however, that now and then it will re-expand after com- 
pression has lasted from two or three months. Another serious 
danger accompanying the pressure produced by the liquid is 
the inactivity of the blood- and lymph-vessels of the walls of 
the cavity; for in such a case total compression means absence 
of function (absorption). Thus, even a partial removal of the 
fluid, with partial relief to the vessels, is quite often the first 
stimulus to absorption and the commencement of recovery. 

In order to either make or confirm the diagnosis of exuda- 
tive pleurisy, an explorative puncture is often resorted to. For, 
in spite of a number of rational symptoms, the positive diag- 
nosis of a pleural effusion or exudation is sometimes impossible 
without its ocular confirmation. The puncture is made near 
the upper edge of a rib to avoid the course of the intercostal 
artery, while the hand of the diseased side is carried to the 
opposite shoulder to widen the intercostal spaces. The pain 



DISEASES OF THE RESPIRATORY ORGANS. 503 

of the little operation is diminished by the quickness of its 
performance; besides, a slow introduction of the needle — par- 
ticularly when of larger size — may peel off the pleura from the 
chest wall. In many cases of copious exudation the place 
selected, within certain limits, is a matter of indifference. The 
puncture is mostly made where there is bulging, or a high 
degree of dulness, or more, or less complete absence of respira- 
tory murmur, frequently in the sixth intercostal space poste- 
riorly to the axillary line. When these spaces are narrow, or 
when the patient is restless, it is not always easy to penetrate 
them; these are the cases in which, now and then, the inter- 
costal artery has been wounded, or pain resulted from hitting 
periosteum and bone. When the point of the needle is not 
carried far enough, it may land in the chest wall or in the 
thickened pleura; when too far, it reaches the lung; when in 
a wrong direction, it may be fastened in the liver or in the 
spleen. In such cases the needle is liable to participate in the 
excursions produced by inspiration and expiration, and, when 
withdrawn, will carry blood instead of the contents of the 
pleural cavity. In rare cases it is possible, however, to exhibit 
the latter and still wound the lung. It has happened to me 
to extract pus from a pyothorax. On the very spot of the punc- 
ture the incision was made and a rib exsected; when the inci- 
sion through the pleura was made, there was bleeding from the 
lung. The wound was closed with iodoform gauze, a new punc- 
ture was made at a different locality, pus was found, the rib 
exsected, and again there was, on incision, pulmonary hemor- 
rhage, which also was stopped by compression with iodoform 
gauze. A third puncture and a third excision at last led di- 
rectly into the empyema. The failures were due to extensive 
pleural adhesions, and the deceptive results of the exploring 
punctures to the fact that the needle did not reach pus until 
it had perforated the adhering and twisted lung. 

While an absolute diagnosis cannot always be made without a 
puncture, the results of the latter are sometimes not conclusive. 



504 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Though there be plenty of liquid (serum, pus, blood) in the 
cavity, it may not always follow the sucking piston. The point 
of the needle may first land in the lung after passing through 
liquid; this will enter the instrument only while the needle is 
being slowly withdrawn, provided again that it has not been 
closed by a blood-clot. Therefore, when the puncture is futile, 
the needle ought to be carefully examined as to its perviousness. 
Or the needle is too thin for the contents; pus is quite often 
present where serum was expected; or the needle is caught in 
thick fibrinous deposits. That may happen time and again, and 
lead to serious miscalculations and mistakes. Or the pleurisy 
may be localized, with the result of giving rise to an encysted 
empyema, instead of a general pyothorax. Such localized em- 
pyemata are more frequently met with posteriorly, and upward, 
than low down, where they are usually expected, from the fact 
that it is there that free pleural fluids are found. They are quite 
small sometimes, and not infrequently multiple, and therefore 
hard to find. Puncture after puncture must be made in such 
cases as yield all the rational symptoms of pysemia, and when 
no pus can be readily detected. When finally found, it is not 
always certain to come from a pleural abscess after all. It 
may be derived from a small pulmonary abscess, or from a pyo- 
pneumothorax. In the latter instance, however, and sometimes 
in the former also, there is often air (or gas) found mingled 
with the pus. 

There are other possibilities of mistake. The needle may 
have withdrawn serum only, and yet pus or blood may be 
present; for in patients who have been in a recumbent or semi- 
erect position, as usual with pleuritics, the solid constituents 
of blood and pus will be deposited near the diaphragm. Thus, 
a microscopic examination ought first to complete the diag- 
nosis of the nature of the pleural contents. When pus has been 
found, there is an urgent indication not to procrastinate the 
radical operation, for the puncture channel may become the 
cause of pus-infiltration, and possibly of pyaemia. Particularly 



DISEASES OF THE EESPIBATOEY OEGANS. 505 

is this so when the pus is discolored and malodorous, as it is 
apt to be in cases of pyopneumothorax, or in those which are 
complicated with caries. The latter cases are apt to be at- 
tended with high temperatures (still, there are exceptions), the 
fever being either continuous or irregularly intermittent. Such 
fevers require an exploring puncture at an early date; it is 
mostly delayed too long. Indeed, every case of uncompli- 
cated pleurisy in which a high temperature is incessant for four 
or five days, mainly when complicated with much pain or local 
oedema, becomes suspicious. Even as early as the fourth day 
I have met with large amounts of pus, not only in infants and 
children, who are more apt to develop pleural suppurations, 
but also in adults. Moderately high temperatures, however, 
do not necessarily indicate the use of the needle, for through 
periods of weeks, temperatures of 100J° or 101° may persist 
without meaning anything but the systematic irritation caused 
by a perpetual process of absorption and elimination. Thus, 
after all, there is no positive certainty that can be conveyed 
to the unthinking; here it is, like everywhere in medicine, that 
experience comes handy, when guided by brains. 

Before the operation of puncturing is performed, the skin 
must be thoroughly washed (and disinfected); after the needle 
has been withdrawn, iodoform gauze or bismuth subnitrate 
(or some other disinfectant powder) is applied to the wound 
and covered with adhesive plaster or a bandage. If there be 
pain, ice is applied. At all events, the chest ought to be at 
rest; the patient, if possible, in bed; no exercise or work per- 
mitted for a day. As a remedial agent a simple puncture is 
of no account. When recovery follows an exploring puncture, 
it is spontaneous, and not induced by it; for spontaneous ab- 
sorption of the pleural fluids, both of transudations and exuda- 
tions, is quite frequent. That is mainly so when the liquid is 
serous only and not too excessive; in the latter case, absorption 
begins only when, by means of an aspiration, the pressure by 
which blood- and tymph-vessels are hampered has been in part 



506 THEKAPEUTICS OF INFANCY AND CHILDHOOD. 

relieved. Nor is it infrequent for hemorrhagic exudations, or 
even extravasations, to be absorbed after the solid constituents 
have been deposited on the surfaces of the pleurae. Even the 
results of tubercular pleurisy may disappear, just as ascites 
caused by tubercular peritonitis is apt to get well, whether or 
not tubercle bacilli are found in the fluid. As a rule, in most 
of the cases of spontaneous recovery no microbes are present; 
if they be found, they are mostly the short-lived cocci of 
Fraenkel. No such favorable event, however, need be looked 
for when the long-lived streptococcus and staphylococcus are 
present; still worse is the influence of proteus vulgaris and 
mirabilis in the putrid empyema. Simple encysted empyema, 
however, may finally heal without any operative interference, 
through a process of gradual inspissation and absorption. 

Spontaneous perforation of pyothorax, either through the 
lungs or through the chest wall, may lead to recovery; but it 
is slow, and takes place at the expense of much time, suffering, 
tissue, and usually of future health and vigor. It should never 
be wished or waited for. 

Thoracocentesis ought to be performed soon after the ex- 
ploring puncture. In many cases, when a mere aspiration is 
made, the operation appears simple enough; but it ought to 
be considered serious in all cases, as in many it is. The patient 
must rest quietly and be well supported in the position recom- 
mended for a simple puncture, and so that respiration and cir- 
culation are not unduly interfered with. The needle is inserted 
with the precautions detailed in the remarks I made on 
puncture; if it be caught by a fibrin clot, the latter may 
be detected by a probe introduced through the needle, but 
a second insertion may be required, probably anteriorly and 
superiorly to the first one. Aspiration alone will not cure 
empyema, except occasionally in infants, whose ribs are flexi- 
ble and whose chests can be compressed more readily so as 
to approximate and adjust the walls of the abscess; even 
in them, however, the same operation must not be repeated 



DISEASES OF THE RESPIRATORY ORGANS. 507 

after pus has again been formed, but a more extensive and radi- 
cal operation is to be undertaken. Aspiration is always contra- 
indicated in the empyema of adults, except in a vital indication 
for temporary relief, or when the fluid is hemorrhagic in char- 
acter, or in cases absolutely inoperable. 

During the operation the patient, if it be feasible, ought to 
be kept as much as possible on the diseased side, so as to avoid 
the dyspnoea due to the compression of the lung of the oppo- 
site side and the molestation of the heart. The fluid may be 
permitted to flow so long as the current remains equable during 
inspiration and expiration; the discharge must be stopped when 
the current begins to cease during inspiration. The relief 
given by the removal of a half -pint or a pint is sometimes con- 
siderable; but in young children, with their compressible 
chests and corresponding facility of accommodation to the ex- 
panding lung, it is safe and advisable to entirely empty the 
cavity. If the operation — because of the urgency of indica- 
tions — be performed while exudation is still progressing, and 
dyspnoea return, another thoracocentesis may become necessary 
within a short time. I had to operate twice within a day. If 
the contents be hemorrhagic (from tuberculosis, carcinoma, 
alcoholism, nephritis, a rare occurrence in childhood), as little 
as possible should be withdrawn. 

The operation requires time. It is advisable to interrupt the 
discharge from time to time; for the too rapid entrance of 
air into the bronchi causes violent attacks of coughing (er- 
roneously attributed to the needle irritating the pulmonary 
pleura), or the sudden rush into the expanding lung may give 
rise to large quantities of serous, strongly albuminous, bron- 
chial secretion, or to copious pulmonary oedema, or to hem- 
orrhages with slight surface lesions, or even to considerable 
rupture of pulmonary tissue. Fainting spells are also frequent 
during a rapid escape of serum, sometimes through psychical 
influences, sometimes from cerebral anaemia. In other cases 
(fortunately rare) thrombi formed in the compressed lung, or 



508 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

in the impeded heart, or in the torn surface of the bronchi may- 
be carried oft' into distant blood-vessels; thus, emboli are 
known to have been swept into the pulmonary artery or into 
the artery of a fossa Sylvii. 

After the operation the wound must be cared for as I sug- 
gested above, when speaking of the treatment of a mere punc- 
ture made for the purpose of a diagnosis. In addition, it is 
advisable to enforce absolute rest and to apply for some time 
an ice-bag to the part. This is particularly necessary when 
there is acute pain. Should this be severe, morphine may be 
used subcutaneously, but in uncommonly small doses, because 
its absorption is very rapid and its effect much more marked 
here than under ordinary circumstances. 

The simple operation of aspiration does not suffice in cases 
of exudative pleurisy in which the pleural contents hold, or 
consist of, pus, either laudable or putrid. As I mentioned 
before, pus may be found as early as the fourth day, and then 
it is often on both sides. When high fever attends such cases, 
far from contraindicating a radical operation, they require it 
for immediate relief. If such relief be not obtained after a 
reasonable time, it is either because of a complication such as 
pneumonia, pericarditis, or peritonitis, or of some pus con- 
cealed in a recess. The latter ought to be looked for and made 
to discharge; Nelson employed a metal sound for the purpose 
of breaking up adhesions and facilitating the escape of pus. 

The radical operation consists in the making of a large 
aperture, either by a simple incision between two ribs, if pos- 
sible, in the fifth or sixth intercostal space between the mam- 
millary and axillary lines, or by incision with the exsection of 
a piece of rib from one-third of an inch to an inch in length, 
large enough to admit two fair-sized drainage-tubes. The 
opening is insufficient so long as it gives no exit to the clots 
of fibrin, which sometimes are as large and perplexing as their 
presence is unsuspected. It is on their ready and speedy re- 
moval that the duration of convalescence or the favorable or 



DISEASES OF THE EESPIKATOEY ORGANS. 509 

fatal termination depends. Therefore they should be removed 
at the time of the operation. There is no better means than to 
dislodge them from the surface of the lung and of the chest 
wall by the index-finger introduced into the cavity. During 
the following irrigation they are washed out or appear at the 
opening and may be caught in a forceps. There are those 
who, as the presence or absence of these large masses can- 
not be diagnosticated, insist upon exsection in every case of 
empyema, no matter whether of recent date or of long standing. 
At all events, whenever there has been a continued or a pya?mic 
fever, a great deal of pain, an intercostal oedema, or a complica- 
tion with infectious embolism, pyopneumothorax, tuberculosis, 
or superficial pulmonary or hepatic abscess, the exsection of a 
large piece of rib is indispensable. After the operation has 
been completed, the cavity may be thoroughly washed with 
quarts of warm saline (6 : 1000) or of Thiersch's solution. 
Stronger antiseptics should be avoided, or used only — largely 
diluted — when the fluid is decomposed. In the latter case 
irrigations are indispensable; they may be dispensed with alto- 
gether when pus is absolutely laudable and the patient in a 
low condition. The dressing should be soft, thick, and aseptic. 
The frequency of the removal of this dressing and the number 
of injections depend on the nature and quantity of the pleural 
secretion. In the majority of cases it is safe to wait until the 
dressing becomes moist. When the lungs expand readily, many 
days may elapse before the first dressing is removed and another 
one substituted. For the sake of thorough drainage the patient 
should, however, be placed horizontally (the incision being the 
most dependent part) with raised hips, at least three times a 
day and ordered to cough as hard as possible (Koenig). When, 
however, the pus is putrid, and in cases of complications such 
as are mentioned above, a daily change of dressing and daily 
irrigations, with occasional short interruptions, should take 
place. To expand the lungs and to promote the required adhe- 
sion between the pleura? the child should amuse himself with 



510 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

blowing soap-bubbles, trumpeting, or with W. T. James's enter- 
taining exercise. He is made to blow air into a bottle and dis- 
lodge the water (colored with f uchsine, methylene blue, or such 
like) into another one by means of a Simple system of rubber 
tubes. When fistulae remain behind, or the abscess cannot close 
because of the lung being kept from expanding by pleuritic 
thickening over it, larger pieces of one or more ribs must be 
removed to enable the chest wall to sink in and thereby facili- 
tate the approximation of the walls of the cavity. In these, as 
in many simpler cases, it is necessary to keep the opening 
patent for a long time; this is readily accomplished through 
the slowness of the growth of callus in that region. 

Hydrothorax (fluid with a low specific gravity, less than 1015, 
and from one to five per cent, of albumin) depends on or is 
complicated with malaria, nephritis, cardiac disease, anaemia, 
or cachexia. The cases resulting from scarlatina are among the 
most favorable. Besides the indications afforded by its cause, 
and good nutrition, hydrothorax demands diuretics, such as 
digitalis, sparteine sulphate, caffeine, diuretin, bitartrate of po- 
tassium. The less such patients drink the more readily will the 
fluid be absorbed. Plenty of sodium chloride in food and 
drink will increase renal action. If no reduction of the fluid 
take place, paracentesis is demanded. 

Pneumothorax is a complication or a result of the perfora- 
tion of a cavity, of pulmonary gangrene, of pleural infarction, 
or of perforating empyema, and in many cases of this kind 
pyopneumothorax will be observed. Foreign bodies are more 
apt to produce pneumothorax than whooping-cough, which is 
liable to tear the mediastinum rather than the pleura. Ice 
will relieve local inflammation and pain, so will opium, which, 
moreover, modifies the perturbed respiratory movements. Cases 
of pyopneumothorax which do not readily discharge their pus 
through the lungs demand a counter-opening of the chest wall, 
which should be made, not under a general but a local anaes- 
thetic. 



DISEASES OF THE ORGANS OF CIRCULATION. 

1. The Heart. 

Both in acute and in chronic diseases of the heart the amount 
as well as the quality of food require some modification. In 
many cases the loss or diminution of appetite will regulate the 
former. As a rule, however, the amount taken ought to be 
much less than the same person would lake when in health. 
Not only ought the total quantity to be less, but also that con- 
sumed at each meal should be comparatively small. It is best, 
therefore, to divide the meals into halves and even thirds, so 
as to cause the patient to eat every two or three hours. Di- 
gestibility must be improved by slow eating. The diaphragm 
should not be annoyed by large quantities of food or by the 
evolution of gases. Therefore but few carbohydrates and but 
little fat are to be given, and the digestion of nitrogenous 
foods, such as meats (eggs) and milk, with or without cereals, 
ought to be aided by pepsin and dilute hydrochloric acid. The 
latter is an excellent adjuvant to the digestion of milk prepared 
according to J. Eudisch's formula (p. 23). Or it may be modi- 
fied or mixed according to the rules given by me in the first 
chapter of this book. At all events, milk is the main food to 
be given in cardiac ailments. Its digestion has a further ad- 
vantage in this, that it does not result in the physiological con- 
gestion of the stomach, liver, and spleen, which becomes irk- 
some after large and heavy meals by disturbing circulation 
and thereby adding to the labor of the heart, and that it does 
not contain the large mass of fat-forming elements present in 
the mixed food of healthy advanced childhood or adult age. 
Altogether, it is best to slightly underfeed the patient. 

511 



512 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Thereby the labor of the heart is facilitated, an object which 
must never be lost sight of. For the same reason fast drink- 
ing, even of water, must be avoided, for its sudden absorption 
fills the blood-vessels too suddenly for comfort. Its speedy 
elimination does not diminish the momentary overwork. This 
warning is of particular importance as regards iced liquids, 
which act both by their bulk and by reflex. This advice is by 
no means superfluous, either for medical men or for the sick. 
It was strongly urged by Williams fifty years ago. Stokes pro- 
hibited the use of large quantities of soups or milk. And it has 
been again introduced by Oertel with such impressive emphasis 
that thirsting has become almost fashionable and a craze among 
the fanatics. 

That stimulants, such as coffee, tea, and alcoholic beverages, 
must not form part of the regular diet in cardiac disease is 
self-understood. They may be required as medicinal agents, 
however, upon positive indications. 

In every form of cardiac disease absolute rest of both body 
and mind is among the very first indications. The latter is 
just as important — perhaps more so — here as in diseases of the 
nerves and nerve-centres. Fretting, worrying, crying are det- 
rimental, and must be avoided. Thus, it may become neces- 
sary to take a child out of bed, temporarily, to gratify and 
quiet him; or to change his position, for the recumbent po- 
sition of a hypertrophied heart may cause dragging of the 
phrenic nerve or of the sympathetic plexus; or to raise the 
trunk and head to relieve the intracranial hyperemia and the 
consecutive irritation of the pneumogastric nerve; or to give 
a mild opiate or a dose of bromide of potassium to insure 
quietude or sleep. The child must be permitted to select his 
own position; he knows best where he is most comfortable; 
but rest he must. The diseased heart is in its most favorable 
condition when working least; the number of heart-beats is 
reduced by ten or twenty-five in the recumbent position. Eest 
is not only a curative, but a preventive agent. Many a life- 



DISEASES OF THE ORGANS OF CIRCULATION. 513 

long cardiac affection could be warded off if care were taken 
in time. We are beginning to become more and more aware of 
the frequency of affections of the heart muscle. Myocarditis 
in a chronic, subacute, and acute form is of very frequent oc- 
currence. In or after every case of typhoid fever, scarlatina, 
diphtheria, or small-pox we should be prepared to be overtaken 
by some cardiac disease, either interstitial myocarditis or paren- 
chymatous degeneration. Rest in bed or on the lounge (the 
former is better) will act as a preventive. It ought to be con- 
tinued for weeks in almost every case. Like the paralysis con- 
sequent upon infectious diseases, which develops after weeks, 
heart-disease may occur from the same cause, partly as a 
consequence of actual primary alterations, partly of nerve ex- 
haustion. So long as the pulse becomes more rapid on ex- 
ertion, or on getting out of bed, absolute rest is the best 
remedy and safeguard. In these cases it is not always possi- 
ble to distinguish between functional debility and actual dis- 
ease. Autopsies too frequently tell us of our mistakes. Trifling 
changes in size cannot be measured by percussion, feeble mur- 
murs cannot always be estimated according to their exact value. 
Functional murmurs are not so frequent in the child as in the 
adolescent or the adult. On the other hand, organic cardiac 
diseases have a better chance to be cured — really cured — in 
the young than later. So much the greater is the responsibility 
of the medical man in cases of preventable or remediable car- 
diac disorder. Even patients suffering from the very worst 
forms are apt to feel better within a very few (hours or) days 
after being confined to bed, with strict diet and loose and com- 
fortable clothing. These cases teach us the lesson of what can 
be accomplished through the same regime in milder or in- 
cipient forms, by reducing the labor of the heart and at the 
same time of the voluntary muscles, and by diminishing the 
overactivity as well of the general innervation as of the cardiac 
nerves, both exciting and inhibiting. 

It is difficult to decide to what extent exercise should take 

33 



514 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

the place of rest in individual chronic cases. The hearts of 
patients are as little alike as are their noses and finger-tips, 
and their treatment ought to be as individual as the size and 
shape of their gloves. Neither fit everybody. Nor is the rule 
adopted to-day that which will accomplish the best end in a 
month or a year for the same patient. The heart is neither 
in health nor in disease a uniform body. Its innervation may 
change from minute to minute, its nutrition is dependent on 
sudden or gradual alterations. A heart muscle is influenced 
in its arterial supply, venous discharge, and lymph circulation 
not only by its own health or disease, but by the ever-changing 
conditions of the other organs. Thus, many of the rules given 
one day may not remain valid another. Still, after a fair time 
has elapsed since the occurrence of an acute myocarditis or en- 
docarditis, exercise should be recommended. The child may 
get up and have his quiet play sitting at the table, may begin 
to walk on the level floor, and may indulge in mild gymnastic 
exercise. More must not be permitted until the mucous mem- 
branes become a little more tinged, the arteries fuller, the heart 
quite regular. The systematic rules recommended by Stokes 
and by Oertel refer more to adults, with their incipient fatty 
degeneration and chronic myocarditis, than to children. In 
these, while they bear the imprint of cardiac changes, no iron- 
clad rules hold good. Gentle exercise and long rest should 
alternate. 

Gentle exercise may be replaced or complemented by mas- 
sage of the skin and the muscles, both of which are so essential 
for circulation and metamorphosis. The blood circulating in 
a resting muscle during one minute amounts to 17.5 per cent, 
of its weight; in a contracting muscle to five times as much. 
It is easily seen to what extent massage, hydrotherapeutic irri- 
tation of the whole surface, excitation of the muscles by the 
interrupted current must do good without an exertion of the 
heart muscle. The avoidance of the latter, while the muscles 
are gently exercised by "resistance movements," is the pecu- 



DISEASES OF THE ORGANS OF CIRCULATION. 515 

liarity of the Schott treatment at Nauheim. It is indicated in 
a great many cases; in others it is Oertel's climbing exercises. 
In all, it is the judicious mind and common sense of the physi- 
cian in charge of the individual case. 

The skin requires judicious attention. Exposure to cold, 
with its consecutive contraction of the cutaneous blood-vessels, 
overloads the viscera, retards circulation, and increases the 
labor of the heart muscle. A cold general bath, therefore, is 
dangerous (as also in the atheromatous degeneration of the old) 
in acute carditis (where local application of cold acts quite 
favorably) or in extreme muscular weakness of the heart. On 
the other hand, a brief cold sponge-bath or wash, with thorough 
friction, is an intense stimulant and may be used to advantage 
for a weak heart, unless the extremities be cold and the mucous 
membranes cyanotic. In these latter conditions, hot washes 
and frictions, with or without alcohol, should take its place. 
In the average condition of the diseased heart general hot 
bathing must be avoided. It overstimulates and paralyzes, and 
proves an actual danger in both acute and chronic cases. 
Newspaper readers will remember the reports of people who go 
to the hot or "Turkish" bath with their heads erect and full 
of their own therapeutical wisdom, and leave it with their feet 
forward. A warm bath, the temperature of which ought to be 
over 90° or 92° F., is often relished. In fact, both the talking 
child and the silent will soon tell you the exact temperature 
best adapted to their wants. In these cases requirement and 
comfort are identical. The baths, particularly the first, must 
be limited to a few minutes; at all events, they should never 
be continued after the slightest weakness of the pulse is noted. 
The debilitating or fatiguing effect of the bath must be 
avoided. 

The mineral springs which have obtained a reputation in the 
treatment of chronic heart-disease, like the German Nauheim 
and Oeynhausen, owe their effect to the stimulating action of 
the salts and of the carbonic acid contained in them. 



516 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Like hot water, hot air is contraindicated in heart-disease. 
The wilted forms of the little ones soon show the effects of 
summer heat. A temperature of from 65° to 70° F. and fairly- 
dry air are best for them. High altitudes do not agree with 
cardiac disease, particularly when no compensation has facili- 
tated the heart's action. Compensation is not complete until 
the hypertrophied left ventricle, having become so by mitral 
incompetency, transmits as much blood into the aorta as the 
pulmonary artery does into the lungs. Until that stage has 
been reached, the lungs are comparatively hypersemic and sub- 
ject to catarrh, oedema, or bleeding. In this condition, there- 
fore, the influence of the rarefied air of the high altitudes 
should be avoided; as a rule, I recommend an altitude of not 
more than from one thousand to fifteen hundred feet to chil- 
dren affected with chronic endocarditis. 

In the therapeutics of the heart it is most important not to 
mistake a functional disturbance of the heart's action for the 
immediate result of heart-disease. The contractions of the 
heart (the pulse), as to number and rhythm, are more fre- 
quently influenced by disorders of other organs or of the or- 
ganic economy in general. The pulse may become arhythmic 
from cardiac (mainly myocardial) disease, but also from men- 
ingitis, from neuroses (chorea, hysteria, epilepsy), from anae- 
mia in convalescence after grave diseases, in chlorosis, in uni- 
versal obesity, even in the apparently healthy; from the 
autoinfection caused by constipation or by jaundice; or from 
the effects of medicines. It is self-evident that all these 
different causes, and not their common symptom, should be 
relieved. 

The functions of the heart and blood-vessels are best con- 
sidered together, from a clinical point of view. Together they 
control the normal blood-pressure and circulation; when these 
are disturbed, it is mostly (not always) the same remedies or 
drugs that influence at the same time the heart and the arteries. 
Such disturbances are either an increase or a lowering of blood- 



DISEASES OF THE ORGANS OF CIRCULATION. 517 

pressure, and alterations in the circulation which are character- 
ized by slowness or frequency of the pulse. In the diseases of 
the young it is mostly cardiac stimulation that is required with 
a view of contracting both heart and arteries. Its indication 
is furnished by primary feebleness of the heart muscle, or that 
which is caused by acute or chronic, inflammatory or infectious 
diseases; sometimes by congenital undersize; by impaired brain 
function after hemorrhages, in syncope, or in chronic cerebral 
anasmia; by insufficient diuresis; by pulmonary oedema; by 
reflexly lowered blood-pressure in shock, in colic, or after ex- 
tensive burns; by hemorrhages; or by toxic dilatation of blood- 
vessels caused by chloral hydrate, nitrites, pilocarpine, or mus- 
carine. 

Blood-pressure and circulation are improved by physical 
means, such as transfusion, salt-water infusion, lowering the 
head and raising the feet, ligature of the extremities, manual 
compression of the abdominal aorta, and hydrotherapy in dif- 
ferent forms. The centres of the medulla and of the spinal cord 
are influenced by strychnine and ergot, the vasomotor centres 
and the heart by caffeine, camphor, ammonium, and musk, the 
vasomotor centres and the peripherous vasomotor nerves by hy- 
drastis, the heart by alcohol, atropia, and sparteine, the heart 
and arteries by digitalis, strophanthus, adonis, convallaria, 
hellebore, and apocynum. 

Among the principal remedies employed for the purpose of 
reducing blood-pressure and dilating peripherous vessels are 
warm baths, or foot-baths with or without mustard, warm 
clothing, rest in bed, narcotics, such as morphine and chloral 
hydrate, acids and alkalies, and the nitrites. 

At the head of the list of heart and blood-vessel stimulants 
stands digitalis. It increases the action of the heart muscle 
and thereby increases cardiac pressure. It is indicated in all 
conditions of weakness of the heart muscle so long as the latter 
is not decomposed. This condition hardly ever occurs primarily 
in childhood, for uncomplicated fatty degeneration in which 



518 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

digitalis is contraindicated is almost unknown at an early age. 
Secondary parenchymatous degeneration is a frequent occur- 
rence in and after infectious diseases, such as typhoid fever, 
dysentery, rheumatism, scarlatina, diphtheria, and others. 
Digitalis is useless and sometimes worse than useless in nervous 
affections, such as the palpations of Graves's disease, of neu- 
rasthenia, or of fever. In all probability the effect of digitalis 
is mostly felt at first in the left ventricle, which is more muscu- 
lar, but in the right ventricle almost as soon. By acting on the 
left ventricle it regulates the general circulation and facilitates 
aspiration of the venous blood and the circulation in the lungs 
and in the right heart. During its administration the contrac- 
tions of the heart become more vigorous and less frequent, the 
arterial pulse slower and fuller, the urine increases in quantity, 
cyanosis and dyspnoea diminish, and dropsical symptoms disap- 
pear gradually. When large doses have been given for some 
time, accumulation of the effect takes place. The pulse be- 
comes quite slow and irregular, and vomiting sets in. If pos- 
sible, this effect should be avoided. 

For how long a time may digitalis be administered when 
given in moderate doses? This question has often been asked 
and as often answered. Unfortunately, the preparations sold 
in the markets are of different strengths and vary too often; so 
it is best to rely on preparations which are not liable to spoil 
on one's hands. With that proviso, I can say, from an experi- 
ence of several dozens of years, that I cannot agree with those 
who stop the administration of digitalis after a few days, to 
begin again after an intermission. Moderate doses may be 
given day after day for months without any ill effect and with 
great benefit. Nor is it necessary to alternate between cardiac 
stimulants so long as no uncomfortable effect of digitalis makes 
its appearance. 

In practice we are often disappointed. The preparations are 
as various as are the firms of wholesale, or sometimes retail, 
manufacturers or tradesmen. The United States Pharma- 



DISEASES OF THE ORGANS OF CIRCULATION. 519 

copoea is, after all, the best stand-by of the practitioner, and 
its list of drugs and that of the National Formulary of the 
Pharmaceutical Association are sufficiently large to supply any 
taste. The infusion of digitalis, when reliable, may be given 
to a six-year-old child in doses of a teaspoonful two or four 
or five times a day, the fluid extract (I have often expressed 
my predilection for "Squibb's") two or three minims daily, the 
solid extract from one-half to one grain daily (0.03-0.06). 
They are not equivalent, the infusion being weaker by contain- 
ing the digitonin, which is highly soluble in water and acts 
rather as an antidote to digitalin and digitoxin. The tincture 
of digitalis, when reliable (not fixed up by mixing a poor "fluid 
extract" with alcohol), ought to be a competent equivalent of 
the fluid extract, if made of the English leaf. Indeed, chil- 
dren bear digitalis, and cardiac stimulants generally, better 
than adults, and in comparatively larger doses. Digitalin I 
have used a great deal. Unfortunately, the wares sold by that 
name are very unequal: they are resinoids, not alkaloids. In 
order to have — no matter whether resinoid or alkaloid — an 
article of probable uniformity, I prefer to prescribe Merck's. 
(Schmiedeberg's preparation may prove preferable.) A child 
of six years may take one-hundredth of a grain (1J milli- 
grammes) from three to ten times a day. I have often been 
obliged to give much larger doses to obtain its action; for, while 
in chronic cases we may safely spend some time on developing 
an effect, in urgent and acute cases one or more large doses 
should — nay, must — be given to accomplish the desired end 
immediately. In urgent cases a six-year-old child must take 
from one to five minims of the fluid extract at once. That 
dose may be repeated after a few hours, and perhaps again, 
until the effect is perceptible. Then it is time to slacken off 
or stop altogether. It is particularly in those cases in which 
the pulmonary circulation is obstructed, either by local inflam- 
matory processes or by cardiac incompetency, that this mode 
of proceeding is advisable. 



520 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

The effect of digitalis is not limited to the heart; the arteries 
are also affected by it. On this account digitalis is often con- 
traindicated in senile affections of the whole vascular system. 
As they (atheromatous conditions) are not found (except in a 
few stray cases of the literature) in infancy and childhood, this 
contraindication is rare in early age. There is a single excep- 
tion, however, to this rule, — viz., in abnormal congenital small- 
ness of the arteries, which is not so excessively rare as may be 
presumed, and is a frequent cause of lifelong migraine, neu- 
rasthenia, hysteria, and chlorosis. In these conditions, thus 
caused, digitalis is not well tolerated. 

In those cases in which the effect of digitalis appears to be 
retarded, or the practitioner has "reason to doubt the qualities 
of his drug," another one may be substituted for it or combined 
with it. I plead for occasional combinations of drugs. The 
"'simple prescription" flag of the "one drug only" fanatics 
waves over a childish affectation. They forget they are pre- 
scribing half a dozen different articles in their "one drug" digi- 
talis. Moreover, when the heart requires stimulation, we 
should remember that it is a composite organ; the muscle, the 
ganglia, the pneumogastric, sympathetic, and vasomotor nerves 
are suffering simultaneously. The tincture of strophanthus may 
be taken by the same child to the daily amount of from six to 
twenty-five minims; the fluid extract of convallaria majalis in 
the same or somewhat larger doses. Again I suggest that in 
most cases it is best to ascertain the moderate dose to be ad- 
ministered a long time in succession by giving a good dose 
from the very beginning and watching its effect. Of the sul- 
phate of sparteine (better than other preparations of scoparius) 
eight or ten doses are required daily, altogether amounting to 
from one-half to two and a half grains (0.03-0.15). Caffeine 
from two to ten grains, or the salicylate (or benzoate) of sodio- 
caffeine from four to fifteen grains a day, are fair doses, the 
effect of which will be pleasant in most cases. In a former 
chapter of this book (p. 77) I have alluded to the subcutaneous 



DISEASES OF THE ORGANS OF CIRCULATION. 521 

use of the latter; it dissolves readily in twice its weight of water 
and is not a local irritant; it is therefore easily employed. The 
effect of these injections is often marked. More than a dozen 
years ago I published a case of cardiac pulmonary oedema, 
among others, in which recovery was the undoubted result of 
their use. There is, however, a positive contraindication to the 
use of caffeine (and coffee), — viz., cerebral hyperemia, either 
active or passive, or a tendency to convulsions. The same con- 
traindication holds good for sulphate of strychnine which has 
conquered a trusted place as a cardiac stimulant. If there be 
time, it may be given internally, daily, to the amount of one- 
sixtieth to one- twentieth of a grain (0.001-0.003) for many 
days or weeks in succession. Urgent cases require its subcu- 
taneous administration. Large doses, up to one-fourth to one- 
third grain (15-20 milligrammes), may be given to a child of 
ten years in emergencies of collapse and sepsis in a day, but 
such doses cannot be continued. The salicylate of sodio- 
theobromine has been introduced (as "diuretin") by G. See. 
It is a diuretic rather than a cardiac stimulant, and, unlike the 
former, it is often found wanting. Calomel in small doses is 
certainly a cardiac sedative, and, as it is surely a diuretic, it 
is entitled to the many praises bestowed on it rather by the 
older than by modern physicians. Salines owe their effect upon 
the heart mainly to their action on the digestive and the 
urinary organs, with the exception of the bromides and iodides, 
the former of which act as sedatives, and thus save labor and 
soothe irritation. The iodide of potassium has a more direct 
effect. It dilates arteries, diminishes arterial tension, and aids 
elimination through the bronchial mucous membranes and the 
kidneys. Obstructions of the pulmonary circulation depending 
on the heart are its happy indication. Sclerosis of the coronary 
arteries is not found in the young; therefore this is an indica- 
tion exclusively belonging to advanced age. A child of six 
years may readily take from five to twenty grains (0.3-1.25) 
a day, in three or four doses, in plenty of water, after meals. 



522 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

It need not often be interrupted because of the gastric symp- 
toms produced. The nitrites and their preparations play an im- 
portant part in lowering blood-pressure. They dilate blood- 
vessels by paralyzing the vasomotor centres (not the central 
nervous system) and the peripherous vessels. Large doses 
transform haemoglobin into methaemoglobin and thereby cause 
cyanosis, dyspnoea, and sometimes methaemoglobinuria. Nitrite 
of amyl may be inhaled in drop doses; nitroglycerin (trinitrite, 
glonoin) is given in doses of from one five-hundredth to one 
two-hundred-and-fiftieth grain (J-J milligramme) in solution. 
The spiritus glonoini of the United States Pharmacopoeia con- 
tains one one-hundredth grain in one drop. The effect of nitrite 
of sodium, one to four grains (0.06-0.25) a day, in solution or in 
powder, is milder but more permanent. Sweet spirits of nitre 
is of an unequal composition; its action on the kidneys is more 
pronounced than that on the circulation in general. 

There are occasional cases in which the secondary compen- 
sation required by mitral incompetency is not fully established, 
and serious disturbances of the circulation arise therefrom. 
The dangerous symptoms may be cyanosis and pulmonary (or) 
and cerebral oedema. There are stupor or convulsions, dysp- 
noea, cyanosis, dilated veins, cold extremities, and a small and 
intermitting pulse. It is in these cases that a few of the above- 
mentioned large doses of digitalis may do good; here it is that 
wavering and indecision become criminal. Whenever digitalis 
does not have any effect, a venesection may. Our ancestors 
were less pusillanimous. Maybe they overdid bleeding, but in 
an urgent case they did not fail to open a vein. I know that I 
have several times saved the lives of children (and adults) by 
opening a vein quickly. 

Chronic (and sometimes the final termination of acute) car- 
diac diseases may lead to heart-failure. In such cases stimu- 
lants are indicated. Alcohol must not be given by itself and 
in large doses in cerebral hyperaemia of any kind. A child 
of six years may take from three to twenty grains (0.2-1.25) of 



DISEASES OF THE ORGANS OF CIRCULATION. 523 

camphor internally; subcutaneously, a solution of one part in 
five of sweet almond oil should be used, and from five to fifteen 
drops injected repeatedly. Ether may be given, in doses of 
from three to ten drops, in alcohol and water, and ammonium 
carbonate, in frequently repeated doses of from one-half to two 
grains (0.03-0.125), in anise-seed water or in milk. Siberian 
musk internally, strychnine subcutaneously, are required. The 
more urgent the case appears to be the greater is the indication 
for combining several of these remedies. 

Myocarditis. — Though myocarditis, both acute or chronic, 
is by no means so common in the child as in the adult, it is 
nevertheless not infrequent; it is, indeed, remarkable to ob- 
serve how often it is not diagnosticated, or how little its occur- 
rence is appreciated. The disease is met with either in con- 
nection with endocarditis, pericarditis, rheumatism, etc., or is 
spontaneous and uncomplicated. 

In its treatment muscle stimulants must not be given. Digi- 
talis is contraindicated. The recommendation of Heffen, to ad- 
minister ergot, I cannot approve of, for by its action on the 
muscular fibres it increases vascular pressure, and thereby 
secondarily the labor of the inflamed heart muscle. What- 
ever relieves this temporarily is welcome. Therefore, iodide of 
potassium combined with a bromide will act favorably. This 
is also the place for morphine, either in large doses at long 
intervals or in small doses more frequently administered, to- 
gether with ice to the chest. During attacks of collapse, or 
during weakness or prostration, ether, camphor, and alcohol 
should be given, either internally or in an urgent case subcu- 
taneously. A dose of calomel will relieve the bowels. Enemata 
for the same purpose daily, for regular evacuations are the 
best regulators of intra-abdominal circulation. In chronic 
cases iron may safely be given with the iodide; not in acute 
ones, which are injured by it through the increase of vascular 
irritation. Absolute rest, both physical and mental, is essen- 
tial. The extremities should be kept warm (stockings). Deri- 



524 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

vation by extensive mustard plasters and by hot foot-baths 
taken in a semi-recumbent position should be tried. A very 
small pulse demands nitrites. 

Endocarditis. — The treatment of this disease is more prom- 
ising in the child than in the adult, for entire recovery is more 
frequent in early life than later; but it is important that the 
diagnosis should be made early. In order not to be taken un- 
awares, we ought to remember that endocarditis may be present 
without, at least for some time, exhibiting a murmur; there are, 
indeed, cases which run their full course without a murmur. 
This is eminently so in ulcerous endocarditis. On the other 
hand, it is also necessary to remember that functional murmurs 
are not so common in the child as they are in the adult. Thus, 
every murmur — though there be no hypertrophy developed as 
yet — should be suspected of being dependent on organic dis- 
ease. This may also be surmised in most cases of acute chorea, 
which sometimes precedes and ushers in, instead of following, 
endocarditis; and in every case of articular rheumatism, the 
symptoms of which have been described in a former chapter of 
this book as sometimes so slight as to be easily overlooked 
(p. 286). Acute endocarditis is also common as a sequela of 
the chronic form, and as part of septico-pyasmia. It is not un- 
common as the result of acute and chronic nephritis, and of 
infectious diseases, such as scarlatina, measles, typhoid fever, 
variola, tuberculosis, and carcinosis, and is frequently com- 
plicated — mostly through the intercession of pericarditis — 
with pneumonia and pleurisy. Frequent and careful examina- 
tion, therefore, during the existence of such ailments, while it 
facilitates an exact and complete diagnosis, suggests the best 
method of prophylaxis. Most of the cases of endocarditis we 
meet with in children being due to acute rheumatism, every 
case of the latter, though ever so slight, must be watched, put 
to bed, and treated with salicylate of sodium. Almost every 
form of "growing pain" ought to be so treated, and in no case 
of infectious disease must the patient be permitted to leave 



DISEASES OF THE ORGANS OF CIRCULATION. 525 

the bed before much of his previous strength has been re- 
stored. 

The special treatment of acute endocarditis requires absolute 
rest in bed, a dose of calomel sufficient to open the bowels, and 
regular discbarges through the course of the disease rather by 
means of enemata than of purgatives. Frequent but small 
meals, and articles of food as suggested before. If thirst be 
great, drinking should be permitted often rather than much at 
a time. No alcohol in the beginning. Depletion by leeches is 
rarely indicated, and then only when there is a serious com- 
plication with painful pleurisy. In rheumatic endocarditis 
depletion is not tolerated at all. For severe pain which depends 
on pleural complication the subcutaneous injection of a few 
drops of Magendie's solution of morphine is preferable. Dry or 
wet cupping will sometimes relieve in such cases; other deri- 
vants, such as sinapisms, will often suffice. Vesicatories I do 
not advise in an acute case, the patient having enough to suffer 
from nature's infliction. Ice applied in a bag, which must not 
be too heavy, or ice-water cloths well wrung out, are beneficial 
in most cases, rheumatic or other. The head and trunk must 
be raised so as to make the patient as comfortable as possible. 
Blue ointment has been recommended over the heart and other 
places. I cannot say that I have reason to advise it. Strong 
diuretics, such as act by increasing blood-pressure, must not be 
given; mild salines will answer best; a small dose of calomel 
may be given from time to time. According to the indications 
noted above, iodide of potassium, with or without an opiate, 
will answer best, in doses of from fifteen to twenty-five grains 
(1.0-1.75) daily, for a child of six years. An opiate at night 
secures rest; bromide of potassium may be given through the 
day. If the case be rheumatic, as it mostly is, salicylate of 
sodium, from fifteen to thirty grains (1.0-2.0) daily, will be 
tolerated and found serviceable. Phenacetin may take its 
place sometimes, in daily doses, all told, of from eight to twenty 
grains (0.5-1.5). It acts as a febrifuge, an antirheumatic, and 



526 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

a sedative at the same time, better than quinine, a dose of which 
may, however, answer well now and then, particularly during 
remission. No antipyrin, no acetanilide ("antifebrin" of the 
trade). Serious attacks of dyspnoea are best relieved by 
morphine, either internally or subcutaneously, or by lead and 
opium. Drastics will seldom be required and seldom answer 
the purpose. The nitrites may be tried, though they have not 
served me so well, or so often, as I formerly thought I had 
reason to expect; they act best when the pulse is dangerously 
small. When cachexia and debility are prominent symptoms, 
tonics and stimulants are indicated early. In septic cases the 
chloride of iron should be given at an earlier period than in 
those of a purely inflammatory or rheumatic character. Among 
the stimulants, I think highly of camphor and ammonium. 
Among the direct cardiac stimulants enumerated above, digi- 
talis ought to be given only after the acute changes in the 
muscular tissue of the heart have been repaired. (There 
is hardly a case of endocarditis unaccompanied by myocar- 
ditis.) 

It is here that the experience and tact of the practitioner 
have to decide an important point. In the further evolution 
of the case, digitalis with quinine, digitalis with belladonna, 
digitalis with strychnine, or with a bromide, or with an iodide, 
together with stimulation of the peripherous circulation by 
friction, either dry or with alcohol or hot or cold water, find 
their own indications. 

The hygienic treatment of chronic endocarditis has been 
disposed of in former remarks. The medicinal agents of most 
importance are digitalis and iron. Constipation and over- 
exertion must be avoided. In connection with the latter, the 
education and training of the child should be so guided as to 
prepare him for his future trade, business, or vocation. Endo- 
carditis terminating so often in valvular disorders with con- 
secutive hypertrophy, his future life ought not to be exposed, 
if avoidable, to great excitements or hard physical labor. A 



DISEASES OF THE ORGANS OF CIRCULATION. 527 

child so affected must not take coffee, tea, or alcohol in any 
shape as an article of diet. He must not be trained to become 
a military man, a pugilist, or a medical practitioner. 

The management of valvular changes resulting from endo- 
carditis is more successful in childhood than in the adult. 
Compensation is brought about by consecutive hypertrophy; 
thus it is facilitated, about puberty, by the rapid growth of 
the heart at that period of life, and particularly by the in- 
crease in size of the aorta and also of the arteries in general, 
thereby easing the circulation. Besides, vascular disease, which 
is so common in the adult, is a rare exception in the child. 
Moderate exercise contributes its share in increasing the 
growth of muscular tissue of all kinds, and should be rec- 
ommended, according to Beneke,* as also in undersize of the 
heart. 

Pericarditis. — The pericardium is more accessible to the in- 
fluence of cold applications than the heart. They generally act 
well; but we must be prepared to meet with doubtful or no 
success in many cases, for pericarditis is but rarely a primary 
disease. Myocardial changes (fatty degeneration mostly in the 
adult), chronic interstitial myocarditis, or tubercle, or syphilitic 
gumma, or complications with purulent mediastinitis or pleu- 
ritis, are not uncommon. In pneumonia, pleurisy, rheumatism, 

* From birth to the seventh year the volume of the heart increases 
from twenty-three to one hundred cubic centimetres, by no means in 
proportion to the -weight of the body. Still, this increase is very much 
greater than that of the lumen of the arteries when compared with the 
length of the body. The pulmonary artery is wider than the aorta 
until puberty; afterwards they are equal or the aorta becomes larger. 
The subclavian arteries and the common carotids are very wide com- 
pared with the length of the body (thereby causing physiological and 
pathological congestions of the cranium and its contents). Between 
seven and fifteen years the volume of the heart is from one hundred 
and thirty to one hundred and forty cubic centimetres; at that time 
the large arteries increase in absolute width, in accordance with the 
rules given before. 



528 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

and scarlatina pericarditis is not unusual. The internal treat- 
ment of pericarditis is, therefore, in part directed by the com- 
plications. Digitalis is indicated mainly in cases which are 
rather complicated; strophanthus, convallaria, and iodide of 
potassium may take its place or be combined with it, according 
to the suggestions made before. Morphine is demanded in 
most cases, if only to give rest for the night. The fever may 
require phenacetin or (during a remission) quinine. After the 
fever has disappeared, or while it is waning, absorption of the 
effusion may be promoted by caffeine, sparteine, diuretin, 
iodides, and a vesicatory over the heart. Effusion into the 
pericardium is not often so copious as to produce suffocation, 
but I am afraid that puncture of the pericardium to relieve the 
fatal pressure is not made so often as it ought to be. Fortu- 
nately, errors in the diagnosis are not very easily made; still, 
they do occur, for I have been called to perform paracentesis 
where there was some pericarditis, more hypertrophy, and 
much pleurisy. The operation is not difficult, the liquid being 
so copious as to give the heart ample space to recede in a semi- 
recumbent position. The aspiration can be made in the mam- 
millary line, in the sixth intercostal space. In the same 
neighborhood, at the upper margin of the fifth or sixth rib, 
the incision can be made to remove pus, and irrigations may be 
made afterwards. Drainage has also been established in such 
cases. The heart has been punctured during the aspiration 
without evil result; but I am not prepared to say, even with 
Biedert, that "the puncturing of the heart is not connected 
with any danger." 

Hydropericardium, no matter from what cause, must be 
treated on the same principles as those which are valid for 
hydrothorax. 

Syphilis of the pericardium and of the heart, if diagnosti- 
cated, require their own specific treatment. 

Congenital anomalies of the heart claim attention from the 
moment of birth. The newly-born candidate for cyanosis is 



DISEASES OF THE ORGANS OF CIRCULATION. 529 

liable to suffer from asphyxia, the rules for the treatment of 
which need no repetition here. When the troubles, being the 
result of embryonic arrests of development or of fcetal inflam- 
mations, prove incurable, almost the only thing to be done 
for the little sufferers is to protect them as much as possible. 
If they be so unfortunate as to grow up, exercise should be 
avoided, — indeed, is avoided. Alcohol is indicated in condi- 
tions of collapse only; no blood must ever be taken; laxatives 
should be sparely given if at all. The temperature in which 
the little waifs are to live ought to be equable, moderately 
warm, their wearing apparel warm and comfortable. Conges- 
tive disorders which would require the use of cold in otherwise 
healthy children must mostly do without it, as the patients 
seldom bear it. Mild vegetable acids are coveted by most. 
Only those who appear to develop hypertrophy of the heart 
should take digitalis or strophanthus. Small doses of an opiate 
will often relieve their discomfort and dyspnoea. The combina- 
tion of digitalis with iodides, administered for months in suc- 
cession, gave relief in a number of cases where the patients 
lived four years and more. 

There are anomalies of the infant heart which are congenital, 
or nearly so, and still not comparable in dignity to arrests of 
development. Eheumatism, scarlatina (rarely), or inflamma- 
tions of some intrathoracic viscus, when contracted in early life, 
may result in cardiac complications. They are on the left 
side of the heart (while fcetal endocarditis affects the right 
half pre-eminently). Hematoma at the free margin of the 
mitral valve is formed immediately, or soon after birth, below 
the endocardium. It is liable to disappear, and with it the 
systolic mitral murmur caused by it; but excrescences, hard 
noduli (Cruveilhier), cicatrization, and insufficiency of the 
mitral valve may persist. (Luschka, Yirch. Arch., xi.) The 
latter is easily diagnosticated and requires the usual treatment 
of acquired chronic endocarditis. 

Congenital undersize of the heart does not appear to be so 

34 



530 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

frequent as that of the arteries. Indeed, in many cases of under- 
sized arteries it was found of normal size, or somewhat larger. 
In the latter case the heart was not always hypertrophic; on 
the contrary, in most instances there was some fatty degenera- 
tion of the flabby muscle. Like every small organ, the small 
heart, whenever found, may be built up by moderate and per- 
sistent gymnastic exercise, a small dose of strychnine given 
three times a day for weeks or months in succession, cold 
washing and friction and an altitude of one thousand to 
fifteen hundred feet. A certain amount of muscular hyper- 
trophy will probably result from it; it is quite welcome, for 
the labor of the heart requires either an organ of sufficient 
size or one of unusual strength. 

2. Blood-Vessels. 
The structure of the blood-vessels may be very defective, the 
walls being thin, fragile, and pervious. In such cases hemor- 
rhage, small or copious, is a frequent symptom. The frequency 
of hemorrhages in the newly-born, leading, when in the cranial 
cavity, to asphyxia, convulsions, idiocy, or early death, is 
caused by the thinness of the vessel walls, whose tissue has not 
yet quite evolved from its embryonal condition. This, or a 
similar condition, may continue for life. This hypoplastic 
state, however, is not, of necessity, general: it may be local. 
The early nose-bleedings of some, though they have no heart- 
disease, and the congenital tendency to aneurism in places 
where the elastic tissue, either from arrest of local development, 
or by microbic destruction, is either scanty or absent (mostly at 
the origin of branches), prove the occasional occurrence of 
these circumscribed and local defects. A uniform thinness of 
the arteries, however, is most likely to be complicated with 
narrowness, which has been studied by Virchow, See, and 
others in its relation to incurable chlorosis, palpitation, and 
cardiac asthma. That thinness which predisposes to fatty 
degeneration of the intima and media, to sclerosis of the ad- 



DISEASES OF THE OKGANS OF CIRCULATION. 531 

ventitia, to atheromatous endarteritis, and to the formation of 
aneurism at an early age has not been made the subject of 
active treatment, so far as I know, except by myself. The 
number of such cases is naturally small compared with the 
total number of a large practice or clinic; but I feel convinced 
that the administration of phosphorus, — not phosphates of any 
kind, — with its stimulant effect on the growth of connective 
tissue in general, has rendered me good service in habitual ten- 
dency to cutaneous, mucous, and internal hemorrhages. Ecemo- 
philia of moderate degrees appeared to improve under its use, 
and the children to be safer and better developed. The dose 
for a child of three years should be from one-fiftieth to one- 
thirtieth of a grain (0.001-0.002) daily; that means from two 
to three minims of the oleum phosphoratum, or from one to 
one and a half teaspoonfuls daily of the elixir phosphori 
(United States Pharmacopoeia of 1890). 

Thrombosis of veins in general, and of the sinuses of the dura 
mater in particular, is the result of retardation of the (general 
or) local circulation and of coagulation of blood by marasmus 
from whatever cause: rapid elimination of water (cholera in- 
fantum), debility of the heart, pressure on veins, or inflamma- 
tion in the neighborhood (for instance, caries of the petrous 
bone). In the same way thrombosis of the femoral vein may 
be caused by peritonitis or by a pelvic tumor. In the cranium 
the right transverse sinus is most frequently affected, but quite 
often also the inferior petrous, cavernous, and longitudinal 
sinuses. Such thromboses cause hyperemia, oedema, or extrav- 
asations; it is by their symptoms that the diagnosis is made. 
The treatment must be preventive in order to be successful. 
Early attention to the ear and mastoid process, treatment of 
diarrhoea before inspissation of the blood and heart-failure take 
place, timely stimulating and roborant treatment, and not pro 
re nata, — that is, when it is just a little too late, — are the best 
preventives. The subcutaneous injection of large quantities 
of warm sterilized water, with chloride of sodium (1000 : 7), 



532 THEEAPEUTICS OF INFANCY AND CHILDHOOD. 

is capable of preventing the inspissation of the blood which 
results from acute and copious diarrhoea, and often proves life- 
saving. 

Congenital local dilatations of blood-vessels, capillaries, 
smallest veins, and smallest arteries, together with an increase 
of their number, and mostly with incompetent structure, are 
known by the names of ncevus, telangiectasia, angioma. Their 
color depends on the nature of the blood-vessels composing 
the anomaly, also on their distance from the surface, their size 
on the extension of the morbid process, and their size and con- 
sistency on the admixture of connective tissue. They are 
found in all sorts of tissues and organs, mostly on the surface 
of the body. In the subcutaneous tissue, when mixed with 
much connective tissue, they are liable, after having remained 
unchanged for many years, to undergo sarcomatous degenera- 
tion. Therefore, and because of their tendency to rapid growth 
in every direction, with increasing deformity and possible dan- 
ger from hemorrhage, the early removal of all those which do 
not exhibit from the beginning a tendency to fade and finally 
disappear is indicated. The methods followed to obtain that 
end are very numerous. Vaccination over a nsevus will gen- 
erally destroy it, but may do so but partially, and will leave 
a bad scar. The plasters of tartar emetic and of Vienna paste 
cannot be controlled to such an extent as to destroy the growth 
only. Injections of the perchloride or of the subsulphate of 
iron are known to have given rise to extensive thrombosis, 
gangrene, and death; injections of alcohol have been tried, 
but have not, I think, reached further than the ear of the 
medical public. Corrosive sublimate in collodion (1 : 8) is an 
excellent caustic where the naevus is not extensive, particularly 
on the head; it rarely requires more than a single application. 
Fuming nitric acid is perhaps the best of all local applications; 
the pain is but temporary, and the effect circumscribed and 
fairly thorough. But it ought to be used for superficial naevi. 
only, and even then requires repetition in a number of in- 



DISEASES OF THE ORGANS OF CIRCULATION. 533 

stances. Excision is a good method if the operation can be 
performed in a short time and all the morbid parts can be 
safely removed without loss of too much blood. The ligation 
of angiomatous tumors is indicated where they can be entirely 
grasped either without or with the aid of needles run through 
their base; but time is required for them to fall off finally, 
and the wound demands careful and persistent antiseptic treat- 
ment until the danger from local infection has passed and a 
smooth scar has been perfected. Electrolysis has been praised 
very highly, particularly in the treatment of the extensive wine- 
marks. Still, personally, 1 never saw a satisfactory result in 
these cases. There remained always speckled, whitish scars of 
small size alternating with the original discoloration, a result 
which I should not claim as an improvement upon the original 
condition. The actual cautery is the most satisfactory of all 
our remedies; very few will at present use it in any other 
shape than that of the galvanic or the thermo-cautery. The 
heat should not be excessive; white heat destroys blood-vessels 
too rapidly to permit of simultaneous coagulation of the blood, 
and produces hemorrhages. Dull-red heat will accomplish a 
cure. A momentary application suffices for a superficial naevus; 
its action can always be controlled and strictly localized, and 
the formation of the scurf secures against surface infection. 
Nor are large angiomata inaccessible to it. When these are to 
be destroyed, it is best not to attempt too much at first. It is 
unnecessary to destroy everything; long after the direct effect 
has passed away, coagulation in the blood-vessels and slowly- 
progressing cicatrization result in the gradual lessening of the 
swelling. When the tumor ceases to diminish in size, the oper- 
ation is repeated, sometimes after many weeks or even months. 
The cautery is then introduced into the very spot where the 
previous application was made. In this way the cicatrix re- 
mains localized. As a general rule, a cicatrix following the 
application of the actual cautery is smooth and becomes more 
so and less perceptible from year to year. 



534 THERAPEUTICS OF INFANCY AND CHILDHOOD. 



3. The Lymph-Vessels. 

Lymphangioma is the dilatation of lymph-vessels, localized 
or multiple, with or without proliferations extending from the 
walls of the lymph-vessels. Careless operation with the knife 
may lead to lymphorrhoea; several I removed with the actual 
cautery. When in the skin, multiple, and connected with hy- 
pertrophy and oedema of the cutis, either localized (neck, shoul- 
der, dorsum, extremities) or diffuse, it is called elephantiasis. 
It may be removed when not so extensive as even to preclude, 
after removal, skin-grafting to replace the defect. 

Of chyluria (lymphorrhoea into the urinary organs), such as 
is frequent in tropical regions under the influence of filaria 
sanguinis, and was observed by Bouchut in a hysterical girl of 
fifteen (no cause known), I have seen one case in a child of 
eleven years. Kamienski has the case of chylous ascites in a 
baby of five weeks. Paracentesis appeared to be harmful, re- 
covery was spontaneous. ("Jahrb. f. Kind.," xli.) 

Cystic lymphangioma (hygroma, on the neck and in the 
axilla) is unilocular or multilocular, slightly movable, fluc- 
tuating, not compressible because there is no longer any 
open communication with the rest of the lymph-system. On 
the neck it may be mistaken for the hygroma resulting from 
a partially patent and endwise obstructed branchial arch. 
The total extirpation is the preferable operation if it can be 
done. Puncture and subsequent irritation by injection of alco- 
hol, or Lugol's solution, or diluted carbolic acid (3-5 per cent.), 
may require repetition in multilocular cases. That is why in- 
cision of the cavities and subsequent iodoform drainage should 
be preferred. 



XI. 

DISEASES OF THE SKIN. 

Burns. — Burns of the first degree require rarely more than 
cooling applications and rest, both general and local, water, 
lead wash of different strengths, oil, and cotton. Persistent 
cold applications are not tolerated. When large blisters have 
been formed, the epidermis should be removed and the sore sur- 
face irrigated with an antiseptic solution or an aseptic steril- 
ized saline solution (6 : 1000) and thoroughly dusted with sub- 
nitrate of bismuth or dermatol. An aseptic dressing then 
applied may remain eight or ten days; after that time the sores 
will generally be found cicatrized. Individual cases and op- 
portunities may command different methods. The time- 
honored application of equal parts of lime-water and oleum lini, 
to which a twentieth of a per cent, of thymol may be added, 
are still much favored. The burn should then be thickly 
covered with aseptic gauze. After this application is removed, 
a fine powder of bismuth nitrate should be spread over the 
wound and the whole covered with gauze again, or an ointment 
containing bismuth, or bismuth and boracic acid, or bismuth 
and zinc may be employed. To thoroughly guard against in- 
fection, the washing of the wound with a three-per-cent. solu- 
tion of carbolic acid, or of salicylic acid, or of boracic acid (not 
so painful as the other two) must precede the application of a 
gauze thoroughly covered with bismuth subnitrate finely pow- 
dered, or with a mixture of bismuth and starch, or the same 
with the addition of from one to two per cent, of salicylic acid. 
Such an application may remain undisturbed for weeks. Ex- 

535 



536 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tensive burns do well in the permanent warm bath. Should 
large defects result, transplantation may be practised after- 
wards; if contractures, extension must be employed in time 
and apparatuses used for a sufficient period. 

The younger the patients the more liable are they to suffer 
from burns, though apparently mild. Reflex symptoms of a 
nervous character are not quite so bad as the transformation 
of haemoglobin into methsemoglobin, or the toxic swelling of 
lymphatic glands, both, or either of which conditions are held 
responsible for the excessive dangerousness of extensive burns. 
Much reaction may set in after a day, with high fever and con- 
vulsions. Therefore the thermometer ought to be consulted 
soon after the accident and the symptoms prevented or treated. 
Diarrhoea is not uncommon, even after moderate burns, and 
requires opium and the regulation of diet; collapse demands 
stimulants, either internal or subcutaneous; and sleeplessness 
appropriate narcotics. 

Burns are more frequent than are the effects of cold, though 
there are patients who suffer every year. Common frost-bites 
are frequent, it is true, and annoying, but rarely of great im- 
portance. The rubbing of red, itching, and swollen parts with 
snow (or with petroleum) is quite effective in mild cases. The 
itching is often relieved by a mild tincture of iodine or by the 
application of a (from three to ten per cent.) solution of nitrate 
of silver or of chloride of calcium in water (1-2 : 100), also by 
camphor in lanolin (1 : 10). The popular remedies of tallow 
and whiskey or, better still, the application of carpenter's glue 
to frost-bites bring relief. This may also be obtained by sur- 
rounding the inflamed swelling by a protecting (corn) plaster. 
Vesicles on the toes and heels, filled with blood and resulting 
in ulcerations, require the latter treatment, together with sub- 
nitrate of bismuth, naphthalin, or cauterization with nitrate of 
silver until granulations spring up, or an ointment of balsam 
of Peru with or without zinc oxide, or bismuth, or applications 
of a three-per-cent. solution of acetate of aluminium. Gangrene 



DISEASES OF THE SKIN. 537 

of the skin or of whole extremities is, fortunately, rare. When 
it occurs it demands rational surgical treatment. 

Erythema is met with at every age of infancy and childhood, 
and depends on a number of causes. The treatment is, there- 
'fore, partly symptomatic, partly causal. In the newly-born, 
from the establishment of an unprecedented cutaneous circula- 
tion and the discontinuation of the intrauterine amniotic 
pressure, the skin becomes red, changes into yellow (alterations 
of haematin), is subject to extensive peeling, and, finally, ob- 
tains its normal pink color under ordinary circumstances. The 
erythema, however, is not always uniform; now and then it 
bears a resemblance to measles, and is attended by fever, but 
not by catarrh. As a rule, it demands no treatment, except 
preventive. The bath must not be hot, the temperature of the 
room not abnormally high, the bedding not hot and oppressive. 
Vaseline, cold cream, or lanolin is useful where the redness 
and the tendency to peeling are very marked. 

In the following months erythema is a common symptom 
when the babies are exposed to pressure or friction by clothing, 
to the heat of the summer, of stoves, bedding, or bathing, to 
irritation by urine, or to the septicemic after-effects of infec- 
tious fevers, such as measles, angina, diphtheria, typhoid, or 
influenza. In some of these cases desquamation is observed; 
it is the mbre readily a cause of mistaken diagnosis the longer 
it lasts and the greater its extent proves to be. Children of 
three or four years, when afflicted with diarrhoea and consecu- 
tive cachexia, are subject to a papular erythema which is mostly 
confined to the gluteal regions and the extremities. Finally, 
thin and feeble children exhibit frequently a general redness, 
sometimes mottled, which lasts as long as does the sluggish 
circulation depending on their general condition. 

The indications for treatment in all of these varieties are 
furnished by the causes. Irritation of the surface should be 
avoided; the patient must not be exposed to abnormal temper- 
atures, either of air or water, or to errors in diet; diarrhoea 



538 THEBAPEUTICS OF INFANCY AND CHILDHOOD. 

and emaciation must be arrested, and vaseline and fats used 
according to necessities. In many cases a full supply of drink- 
ing-water, which is too frequently withheld from the very 
young, corrects the evil by stimulating cutaneous circulation 
and the tendency to perspiration, which is almost absent during 
the first month and very scanty in the second and third. 

Constipated and dyspeptic children are very apt to suffer 
from erythema as the result of intestinal autoinfection, some- 
times to such an extent that the diagnosis between it and scar- 
latina may become doubtful. The difficulty grows in those 
cases in which the intestinal erythema is attended by the corre- 
sponding intestinal fever, an occurrence not at all uncommon. 
Constipation may be congenital or acquired, and may lead to 
the same result. The diagnosis is not always easy for other 
reasons, — viz., the apparent normality of the stomach, the 
absence of diarrhoea, and the actual or alleged absence of flat- 
ulency. This erythema is not uncommon; it may last hours 
or many days, or may alternate with acute attacks of urticaria. 
The latter is, therefore, not always gastric or neurotic, either 
in its acute or chronic form, but may be toxic, and it thus 
shares the etiology of many cases of acne and some of senile 
pruritus. When occurring in the face exclusively, I have seen 
it mistaken for erysipelas. 

This variety of erythema is sometimes seen mostly on the 
hands and feet, is symmetrical, and now and then, like urti- 
caria, has vesicles or bullae (similar to herpes iris). When it ac- 
companies intestinal autoinfection, it is usually accompanied by 
indican and the ether-sulphuric acids in the urine, which is 
liable to be very scanty and of high specific gravity. Skatol and 
indol are found in the faeces. In most cases a purgative (pref- 
erably calomel) will bring speedy relief, but actual and lasting 
aid will only come from prolonged disinfection of the intestinal 
tract by naphthalin, salol, resorcin, oil of peppermint, small 
doses of calomel or bichloride of hydrargyrum, from large 
enemata containing a twentieth of one per cent, of thymol, or 



DISEASES OF THE SKIN. 539 

from such as consist of aromatic infusions (mint, catnip, 
chamomile) exclusively, from occasional purgatives, and from 
the regulation of the diet, which must be such as not to cause 
fermentation and putrefaction. In the employment of the 
sulphites (of sodium and magnesium) I have been rather disap- 
pointed. The use of menthol is not to be recommended; it 
can be swallowed in capsules only, and to atone for its local 
irritation it has no eminent virtues. 

Erythema nodosum may be discussed in connection with this 
subject. It consists of large nodes, whose redness turns yellow 
in the course of the normal alterations of haematin; it is mostly 
seen on the legs, but also along a number of tendons from the 
occiput downward. It requires rest. When it is the result of 
rheumatism, salicylate of sodium is indicated; when it de- 
pends on malaria (Moncorvo), quinine. A six-per-cent. solution 
of nitrate of silver has been recommended for external applica- 
tion. I have used with benefit, I believe, inunctions of oleum 
gaultheriae, of iodide of potassium in glycerin (1 : 2-4), and of 
iodide of potassium and lanolin ointments. 

Erythema complicated with loss otf epidermis, either spon- 
taneously or through irritation by urine or faeces, or by friction 
of the adjoining surfaces of the nates, thighs, axillae, and the 
folds of the neck, together with secretion, and even crusts, is 
called intertrigo. It is mainly noticed in fat, flabby, and 
rhachitical babies, is painful and annoying, and may prove 
dangerous by becoming gangrenous or by inviting the invasion 
of erysipelas or of diphtheria. Therefore, its treatment and cure 
are imperative. The diapers must be soft, not pinned during 
sleep, and frequently changed; the babies must be kept scru- 
pulously clean and bathed at least once a day. A seven-per- 
mille solution of table-salt is more pleasant than water alone. 
Diarrhoea should be relieved by dieting, internal medication, 
and rectal injections. Astringent solutions (sulphate of zinc, 
acetate of aluminium, tannin) would be beneficial but for the 
difficulty of making regular applications; ointments containing 



540 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

zinc oxide, bismuth, tannin, or lead are preferable. Fine pow- 
ders of bismuth subnitrate, of talcum, of amylum, or mixtures 
of two of them, with or without the addition of one or two per 
cent, of salicylic acid, will act satisfactorily. The popular lyco- 
podium powder is not to be recommended. By reason of its 
gluing together it proves irritant, like all foreign bodies. 

Among the circumscribed inflammations of the skin met 
with in children, mostly of advanced age, are acne, lichen, and 
'prurigo. Acne is dependent on an interrupted action of the 
sebaceous follicles. They begin their rapid development about 
the middle of intrauterine life, and are large and numerous at 
birth, particularly over the nose, ear, eyebrows, and around 
the mouth. When obstructed, they exhibit in the infant no 
black-heads like the comedones of the adolescent or adult, but 
are white. Normally, they secrete much tallow, which gives 
the foreheads of many babies their shining, glossy appearance. 
When this tallow accumulates and gets dry, and mixes with 
the scabs of the epidermis and foreign material, such as dust, 
etc., it forms seborrheica of any shade of color between whitish 
and black, which is more difficult to remove because of the 
conservative superstition of the mother than because of its own 
obstinacy. Its importance and its dangers are quite local; it 
interferes with the growth of hair and predisposes to local irri- 
tation of the scalp; it ought to be removed by oil, fat, soap, hot 
water, and brush, and the subjacent hyperemia relieved by an 
astringent ointment. 

When acne has formed (in older children) the comedones 
ought to be squeezed out. For this purpose an old-fashioned 
watch-key with broad edges will prove as serviceable as the 
mechanical devices of instrument-makers. Frequent hot wash- 
ing with green soap, or spirits of soap, followed by ice-cold 
washing, I have found very useful; besides, the skin should be 
washed four times a day with a solution of corrosive sub- 
limate in water, or in alcohol and water (1 : 20 : 2000 or 
1 : 20 : 1000). 



DISEASES OF THE SKIN. 541 

Washing with vinegar dissolves the epidermis cells and thus 
aids in disintegrating and loosening the obnoxious material. 
Various mixtures of emplastrum and unguentum plumbi may 
be employed. After a thorough cleansing with soap, equal 
parts of precipitated sulphur, glycerin, and alcohol (to be pre- 
served in a well-stoppered jar) are applied in the evening and 
washed off in the morning; or beta-naphthol 10 parts, pre- 
cipitated sulphur 50 parts, lanolin or vaseline 25 parts, and 
green soap 25 parts are applied, and removed by washing after 
fifteen or twenty minutes, after which the skin is covered with 
talcum or starch. Only in the very worst forms of acne (for- 
tunately, rare in children) must scarifications be resorted to. 

Lichen is mostly found in its mildest form: strophulus of 
pin-head size, slightly excavated on top, around a hair. It is 
not particularly resistant, but is liable to return. Lichen 
scrofulosorum, however, is apt to be obstinate. It is mostly 
met with in older children, is of a yellowish or red color, and 
forms a circle around a hair. It does not itch very much, but 
by reason of its duration and appearance is quite annoying. 
Locally, warm bathing and frequent ablutions with vinegar and 
water (1 : 3-6) will act well. Antipyrin in a nightly dose will 
relieve itching whenever troublesome, and by its sudorific effect 
will contribute to the disintegration of epidermic accumula- 
tions. The general treatment of scrofula is required on ac- 
count of its causal indication. Lichen acuminatus and planus 
consist of circular nodules congregated round a pigmented spot, 
the first in rows, the second flat. Both are rare in children. 

Prurigo is found, of pin-head size and pink color, on the 
extensor side of extremities and in the gluteal region and on the 
abdomen. In its neighborhood the lymph-bodies swell, and 
chronic pigmentations are frequent. The itching is terrible, 
intolerable, exhausting, and may prove fatal. Twice I saw it 
complicated with or depending on diabetes; in both cases it 
terminated only with the fatal cause. Inunctions of glycerin or 
fat and protracted warm bathing in water or alkaline water 



542 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

should be resorted to. The baths ought to be continued for 
hours, and may be allowed to last half a day. Vinegar will 
dissolve the epidermis. Pilocarpine will do well in subcu- 
taneous injections large enough to produce perspiration. As 
much and as long as permissible it may be combined with anti- 
pyrin; and if subcutaneous injections be found impossible, it 
ought to be administered internally. Tar, sulphur, and green 
soap have been found very useful, when continued for from 
four to six weeks in alternation with warm baths. Wilkinson's 
ointment contains all of them (flor. sulphuris, ol. rusci, aa 10 
parts; sapon. virid., vaselin., aa 20 parts). Kaposi recommends 
naphthol ointment (5 : 100). The addition of five per cent, of 
menthol to every ointment used will prove helpful. But it 
should not be forgotten that the prognosis becomes more 
serious with every month or year of the duration of prurigo, 
and that general and preventive treatment demand urgent 
consideration. Most patients are stricken in their second year; 
thus a hereditary influence is to be suspected in many. Often 
the parents are tubercular. 

Both prurigo and lichen (also acne in the severe form — 
rosacea — of adults) will often be benefited by ichthyol (thiol 
has been recommended for the same purpose, locally) in from 
five- to twenty-per-cent. ointments. It may also be given in- 
ternally when there are hard and irritating infiltrations, in 
daily doses of from five to twelve grains (0.3-0.8). Other inter- 
nal medication is useless, except arsenic, an occasional purga- 
tive, and now and then a sedative (monobromate of camphor 
at bedtime in doses of from two to six grains = 0.125-0.4); 
strict avoidance of stimulants, and moderate use only of meat, 
are the main dietetic rules. 

Furunculosis in the very young does not often exhibit the 
same character as in adults. Both the sebaceous follicles and 
the perspiratory glands being rather patent, there are rarely 
such large and hard indurations. It is often complicated with 
acne, or follows eczema, and may complicate scabies. It is 



DISEASES OF THE SKIN. 543 

frequently found in cachectic infants and children and after 
protracted diarrhoea, generally in the form of multiple and 
cold abscesses; sometimes in connection with tuberculosis. 
These abscesses are liable to lead to extensive suppurations of 
the connective tissue. The skin must be kept disinfected either 
by blue ointment or by corrosive sublimate in water (1 : 2000- 
5000). Abscesses — no matter how many — must be incised and 
disinfected with sublimate solution, or iodoform, or treated 
with the sharp spoon, or filled with antiseptic gauze, according 
to circumstances and to sizes. Now and then these abscesses 
are found near the matrix of the nails, not multiple as in syphi- 
lis, but localized, and are liable to destroy the matrix unless 
incised and disinfected in time. Secondary lymphatic swell- 
ings round the neck will, when benign, disappear after a while. 
If not, they are probably tubercular, and if persistent, without 
a tendency to get smaller, ought to be enucleated. A preven- 
tive measure is the covering up of incipient furuncles with 
some indifferent plaster (saponis, belladonna?; no turpentine) 
to avoid the friction of the clothing. Arsenic in small doses, 
but persistently given, has a favorable effect. 

One of the most common forms of dermatitis in the young 
is eczema in its different forms, from the small vesicular and 
papular, with but slight desquamation or the formation of thin 
scabs, to the purulent variety, impetigo, with moderate crusts, 
and the rapidly growing and pointed ecthyma and rupia. For, 
indeed, all of them are but varieties of the same process. It 
may be microbic in isolated cases, but certainly is not a mi- 
crobic disease generally. It may be complicated, however, with 
a parasitic ailment such as scabies. A disposition is caused 
by the tendency to congestive, catarrhal, or inflammatory dis- 
order such as is understood by "scrofula," not by tuberculosis; 
also by rhachitis, chronic indigestion, and anaemia; also by 
incidental fevers, — for instance, that of vaccinia; indeed, it is 
not uncommon to date the first appearance of eczema back to 
the effect of vaccination. These occasional or constitutional 



544 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

partial causes of eczema must be considered as regards general 
and constitutional treatment. These are the cases apt to be 
benefited first by appropriate diet, then by the protracted use 
of arsenic, the hypophosphites, cod-liver oil, and iron. Still, 
it is important never to be tempted to begin such a treatment in 
an acute attack of eczema, which is more apt to be benefited by 
a few moderate doses of quinine and purgatives. 

Acute eczema is liable to run its course with a great deal 
of swelling and irritation, resembling in these respects ery- 
sipelas. It bears absolutely no water, and in the beginning no 
ointments. Powders of amylum, or of subnitrate of bismuth, 
or oxide of zinc, or aristol, pure or in different proportions, 
with or without the addition of one or three per cent, of sali- 
cylic acid, prove more efficient. After a while the same con- 
stituents may be used as ointments. 

Most of the cases presented for treatment are chronic, either 
in the moist, or crusty, or squamous form. Many of them are 
itching, and are apt to lead to persistent infiltration of the skin, 
even amounting to elephantiasis. In many of them the original 
local causes are still persistent and can and must be relieved 
or removed. All sorts of local irritation are found. Sebor- 
rhea, uncleanliness, secretions of the nose, ear, and eye which 
are permitted to remain and irritate the neighborhood, the oral 
secretion from whatever cause excoriating the cheeks and chin, 
the septic piercing of the ear, the presence of vermin on the 
skin, are all frequent causes of eczema, the predisposition to 
which is established on certain parts of the body where eczema 
is most common (head and face) through the large size of the 
carotids and the physiological congestion and rapid develop- 
ment of the head and all its organs. By mistaking this connec- 
tion, even the protrusion of the teeth has been charged with 
producing eczema. Indeed, everything causing sluggish circu- 
lation and congestion to the surface — the constipation, for in- 
stance, of fat babies, hot bathing, the influence of solar and 
stove heat — may have the same result. 



DISEASES OF THE SKIN. 545 

The effect of protracted eczema on the head is liable to be 
grave by its interfering with the growth of the hair; by caus- 
ing and extending catarrh of the ear and nose, or blepharitis, 
conjunctivitis, or keratitis; by producing open sores and thus 
facilitating the invasion of erysipelas and possibly of tubercle 
germs; by irritating and tumefying the numerous lymph- 
bodies of the neighborhood with the complication of hyper- 
plasia or tuberculosis. Thus, the indications for treatment 
should be considered urgent in every case of eczema; the sooner 
it is suppressed the smaller is the number of complicating dan- 
gers which are direct outgrowths of what appears to be, in most 
cases, a merely local affection. 

The necessity for local as well as general hygienic and 
constitutional — mostly preventive — treatment is pre-eminent. 
The body of the infant must be kept clean, but the local eczema 
should not be touched by water more than is absolutely neces- 
sary; the reaction after the bath is liable to bring out a new 
eruption. If the eruption be on the head, the hair should be 
cropped close. The nails must be kept short so as to prevent 
scratching to a certain degree. Remove thin or thick scabs by 
warm water, soap and water, warm fomentations (not on the 
head), oil, fat, liquor potassii in oil or in cod-liver oil (1 : 8-12). 
Use the comb when the scabs are beginning to loosen. Below 
them the surface is hypera?mic or oozing; therefore the secre- 
tion must be dipped up and stopped as soon as possible. Solu- 
tions of astringents are neither so convenient nor so effective 
as ointments. The official zinc ointment will suffice in many 
cases. Vaseline by itself is irritating. Bismuth subnitrate 5 
parts, with ungt. zinci and vaselin., aa 20 parts, is a good com- 
bination. Such applications may be made from two to five 
times a day. Hebra's ointment is thickly spread on linen and 
the surface covered with it; layers of it may be worn for days 
or weeks. There is no harm in the extensive use of lead; I 
never saw or heard of a case of direct cutaneous absorption 
which stood criticism, but I have seen lead-poisoning in a 

35 



546 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

boy who scraped the lead ointment from his cheeks and ate 
it for many weeks in succession. The formulae now and then 
published in the journals are very numerous; every thoughtful 
practitioner will make or combine his own from bismuth, zinc, 
lead, or tannin. In addition to these, I mention for inveterate 
cases and the scaly form tar (tar, alcohol, and green soap in 
equal quantities, or ol. cadinum 1 part, ol. oliv. 1 part, lanolin. 
10 parts) and hydrargyrum ammoniatum (either the official 
ointment or a modified formula, such as zinc oxide 1 part, 
hydrate of ammonia 1 part, ol. amygdal. dulc. 1 part, fat 10 
parts), and, finally, nitrate of silver. It is mainly in the most 
obstinate chronic cases of eczema — the crustaceous or squa- 
mous variety — that a large surface will heal under the influ- 
ence of a solution of from three to ten to forty per cent, of 
nitrate of silver, thoroughly applied. 

Tar has but one grave inconvenience. On skins which ab- 
sorb rapidly it may prove dangerous to the kidneys. Nausea, 
vomiting, diarrhoea, headaches, vertigo, and a smoky or even 
black urine, occasionally with more than mere albuminuria, 
may be observed. The same, to a greater degree, must be said 
of carbolic acid, which may be added to ointments (2-3 : 100) 
to relieve itching. It requires watching. Where it cannot be 
used, cocaine (2-5 : 100)^ ointment of lead, zinc, or bismuth 
may take its place. Where the surface healing is slow, the pro- 
liferation of tissue can be accelerated by balsam of Peru (1 : 10) 
ointment. Bulkley recommends, even in acute eczema, alumnol, 
one to five per cent, in solution, ten to twenty per cent, in oint- 
ments. 

"Eczema sehorrhoicum" (Unna) is a parasitic (microbic) affec- 
tion. The ointment of zinc should be mixed with four or six 
per cent, of resorcin; or a solution of resorcin (five to ten per 
cent.) in alcohol and glycerin to be used twice a day. 

Pemphigus is more frequently observed in the newly-born 
and very young than in older children, mostly on the face and 
trunk, with a pale or hyperaemic basis, running its course, in- 



DISEASES OF THE SKIN. 547 

elusive of the drying of scabs, in from six to twelve days. It is 
seldom chronic, and mostly so mild that no scabs remain, ex- 
cept when it is complicated with diphtheria or general cachexia. 
The serum (albuminous and mostly neutral or alkaline) con- 
tained in the bullae, which spring up at some distance from 
each other, becomes turbid after some days, but is seldom san- 
guineous. There is rarely any fever. New crops may start up. 
Strelitz and Almquist gave themselves pemphigus through 
cocci. Kiehl found in a single case a fungus resembling very 
much the trichophyton tonsurans. It is often found on the 
children in institutions, and will also spread to nurses or to 
members of the same family; it seems, therefore, to be con- 
tagious, and may get disseminated through careless midwives. 
Isolated cases are the result of hot bathing and bedding. Thus 
it seems that this disseminated pemphigus may be either the 
result of microbes (staphylococci, like those of impetigo) or of 
mere cutaneous irritation, particularly at the time when the 
surface is most vulnerable, that is, in the newly-born. In him 
dermatitis exfoliativa is the result of hot bathing, the hot sea- 
son, perhaps of sepsis. Dermatol, aristol, subnitrate of bis- 
muth, powdered, or in a five- or fifteen-per-cent. lanolin oint- 
ment, with soft covering, warmth to the feet, stimulants, and 
no bathing is the appropriate treatment. The treatment is 
suggested by the causes thus far enumerated. Beware of heat 
and of contagion. Cleanliness and disinfection are required 
as preventive and curative measures. Astringent ointments 
or bismuth powders are demanded locally, particularly where 
the epidermis has been torn off; general roborant treatment is 
required for puny and cachectic children, and antipyretics if 
(in exceptional cases) the temperature rise to an unbearable de- 
gree; for even delirium has been observed. In most cases pow- 
ders of bismuth, talcum, amylum, zinc oxide, etc., render good 
service. 

Pemphigus foliaceus, where no scabs form, but relapses take 
place contiguous to the first starting-point, is serious and apt 



548 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

to terminate fatally. Pemphigus exfoliativus, which, accord- 
ing to Bitter, begins at the mouth and extends all over the 
body, with an angry redness, gangrene, and phlegmons, and is 
fatal in one-half of the cases, requires careful and roborant 
nutrition, astringent ointments and baths, and stimulation. 

Neuropathic affections of the skin are apt to be congenital; 
while not always connected with cerebral defects resulting in 
paralysis or epilepsy, like the papillomata described by Neu- 
mann (fissured warts following the course of a nerve and cov- 
ering the whole side of a body), still, they are serious enough, 
and sometimes not influenced by treatment. The congenital 
disposition to the formation of vesicles is in later life often 
combined with other neuropathic symptoms. The pemphigus 
neuroticus chronicus described by me (Trans. Ass. Am. Phys., 
1894) is of that nature. To this class also belongs urticaria pig- 
mentosa, which yields ever-returning crops, many of them with 
consecutive and persistent pigmentation. Even common warts 
are probably, in many instances, trophic disorders of a neurotic 
character; their sudden appearance in great numbers and their 
sometimes unexpected disappearance seem to prove it. While 
fuming nitric acid is a fair local application, the internal use 
of arsenic is often of much advantage. This is certainly the 
case in what has been noticed first by Hebra as "verrucae 
planse juveniles," and carefully described by Thin. These 
warts are met with in children and adolescents on the face and 
back of the hands and fingers; they are yellowish or reddish 
brown, of the size of a pea or less, flat with a central de- 
pression, and may have frequently been mistaken for lichen 
ruber planus. 

A neuropathic oedema has been described by Widowitz; it 
makes itself known, after exposure to cold, by extensive tume- 
faction with livid edges, and without any complication on the 
part of heart or kidneys. A neurotic cyanosis has been re- 
ported by Tordeus, and by him connected with dentition, viti- 
ligo in a boy of six years by Wladimiroff. 



DISEASES OF THE SKIN. 549 

Symmetrical cutaneous hemorrhage connected with cerebral 
disorder has been reported by Epstein; erythromelalgia in a 
child, by Baginsky; symmetrical cutaneous gangrene (Raymond) 
of feet, nose, and ears, with hemoglobinuria, in a boy of three 
years, by Abercrombie; in children of seven, eleven, and thir- 
teen years, belonging to the same family, by Braman. 

Scleroderma has many of its (fortunately few) victims among 
children. It has been observed in the first year of life (Barth). 
I saw it in a girl of three, a girl of six, a boy of ten, and one of 
thirteen years. It begins with mostly symmetrical circum- 
scribed, mostly longitudinal, discolored hyperplasias, which 
(usually) after a long time lead to atrophy, shrinking, muscular 
immobility, and contractures. I never saw a case in a child or 
an adult that did not give me the impression of a neurotic 
(local, or more frequently central) origin. Mainly in the be- 
ginning mercurial treatment, in long-continued small doses, 
did some good. Salol (salicylic acid) has lately been recom- 
mended by A. Philippson, who reports two recoveries (adults) 
under doses of from two to three grammes (grs. 30-45) daily. 
L. Weber improved a case by giving thyreoid (Med. Monatssch., 
October, 1897). 

Scabies is apt to become chronic in children because it ia 
often mistaken for or complicated with the various forms of 
eczema and "prickly heat." Errors may readily take place 
because it is not pre-eminently the fingers which are affected, 
but also the face, the gluteal region, the abdomen, and the 
joints. These localities constitute a difference from prurigo, in 
which the extensor sides of the extremities are principally af- 
fected. The skin must be thoroughly cleansed with soap every 
morning, after balsam of Peru, or balsam of Peru 15 parts, alco- 
hol 10 parts, or balsam of Peru and vaseline, in equal parts, 
have been copiously applied the evening before. A few such 
applications will suffice, but they stain the linen. The un- 
guentum sulphuris of the Pharmacopoeia is too irritating to be 
applied to the skin of children, but may be mitigated by the ad- 



550 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

dition of fat, styrax liquidus, and olive oil, in equal parts; 
creolin (5-10 parts in 100 parts of olive oil) or naphthol with 
fat (5-15 : 100) will also render good service. The clothing 
must be thoroughly washed in hot soap and water, or disin- 
fected with sulphur. Both naphthol and styrax may irritate 
the kidneys, so that both are contraindicated in children with 
renal affections. In them, Williamson's ointment (ol. rusci, 
flor. sulph., aa 20 parts; sapon. virid., vaselin., aa 40 parts; 
cret. alb., 10 parts) is advisable. 

Impetigo contagiosa has thinner vesicles than pemphigus and 
no fever and no inflammatory basis. It is found on the un- 
covered parts of the body, face, hands, and feet; the vesicles 
are small or large and spread rapidly, and relapses take place. 
Serious results have not been noticed; still, a case of nephritis 
is reported as a sequela in a girl of twelve years. It is met with 
in schools and after wholesale vaccinations, through infection 
by vaccine lymph. Lassar found the staphylococcus aureus. 
As many as a thousand cases have been observed in a single 
epidemic. The treatment must be preventive, if opportunity 
be given; a school in which the disease is found ought to be 
closed temporarily and disinfected. The local (and general) 
treatment is that of a mild eczema. 

Favus is, through its achorion Schoenleini, eminently con- 
tagious from child to child and from animal (rabbit, cat, dog) 
to child, is communicated through beds, caps, and finger-nails, 
and is not confined to the head. A mild treatment may first be 
tried. Green soap and warm fomentations will succeed in re* 
moving the hard masses, and solutions of corrosive sublimate 
(1 : 100-300) and ointments of naphthol (5 per cent.) or pyro- 
gallic acid (10 per cent.) may prove beneficial. Or a ten- (or 
less) per-cent. ointment of chrysarobin may be tried (according 
to Wolff) daily for six weeks, alternating it with a corrosive 
sublimate ointment (1 : 100). After that time, if the treatment 
have been tolerated, the application should be made every other 
day, and later once a week. The unguentum hydrargyri am- 



DISEASES OF THE SKIN. 551 

moniati will do the rest. I rarely saw a case improved without 
epilation, after a thorough removal of the yellow crusts by 
means of green soap and fomentations. Epilation can be done 
by pincers or by the old method of the pitch-cap, which is ap- 
plied after the hair has been cut to one-third or one-half inch 
in length. Biedert modifies the old plan by melting two hun- 
dred and fifty parts of white pitch and four of tallow. The 
mixture is then spread over a cloth from six to eight square 
inches in size, which is fastened on the hair stumps with a hot 
iron and allowed to remain an hour before it is pulled off. This 
procedure is repeated every six or eight days until the cra- 
nium is entirely bald and smooth. The pain can be over- 
come and the cruelty of the necessary process moderated by 
the use of an anaesthetic. Very obstinate deposits must be 
scraped out. 

Herpes tonsurans (from trichophyton tonsurans, a parasite 
very similar to achorion, common among domestic animals: 
circular vesicles, enlarging) requires a treatment similar to that 
of favus, including epilation. Before resorting to it, ointments 
of sulphur, ichthyol, salicylic acid, or chrysarobin may be tried. 
Corrosive sublimate (1 : 100) in solution and naphthol oint- 
ment are very efficacious. 

Molluscum contagiosum (light nodes from which lobulated 
whitish masses containing brilliant oval bodies, perhaps pro- 
tozoa, can be squeezed out, mostly on the uncovered, parts of 
the body) is very contagious and is met with epidemically. 
Communication from child to child or from baby to nurse must 
be guarded against, the morbid growths removed with the sharp 
spoon, and the wounds treated antiseptically (best with car- 
bolic acid); and, finally, if required, with balsam of Peru or 
ointments containing it. 

Lupus is in some of its forms (exfoliativus, tuberosus, ex- 
ulcerans, serpiginosus) not accessible to anything but external 
treatment. Still, the treatment of the patient who, as a rule, 
shows more symptoms of scrofula than of tuberculosis is not 



552 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

excluded. Zinc chloride has been mixed with two or three 
parts of starch and made into a paste with water. Its appli- 
cation is very painful and its effect slow. So are Lannelongue's 
repeated injections of a ten-per-cent. solution of zinc chloride 
in water; still more so Milton's indefinite and persistent use 
of carbolic acid and of a twelve-per-cent. solution of hyperman- 
ganate of potassium (joined to the internal administration of 
arsenic, iodide of potassium, and mercury). Another method 
consists in the repeated application of saturated solutions of 
lactic acid; still another is the use of the sharp spoon, and 
then for three or five days in succession that of a ten-per-cent. 
mixture of pyrogallic acid. Wherever the affected part is not 
too large, and in a convenient locality, excision ought to be 
made and the wound closed; should it be too large for that, 
transplantation may be performed afterwards. At all events, 
the destruction of the morbid part, wherever aimed at, is most 
easily accomplished by the actual thermo- or galvano-cautery. 
Tuberculin has failed here as in other cases of tubercular dis- 
ease. A paste composed of arsenous acid 1 part, hydrarg. sulph. 
rubr. 3 parts, vaseline 15 parts (or another menstruum), 
applied daily for several days in succession, has a deserved 
reputation for destroying the morbid masses. 

Lupus erythematosus has its localized inflammatory cell-infil- 
trations near the surface, particularly in its most' recent dis- 
seminations. That is why it may be most amenable to treat- 
ment. I. Schutz treated nine cases with two daily applications 
of a mixture of 4 parts of Fowler's solution in 20-30 of distilled 
water. When after four or six days the surface became irri- 
tated, a mild powder was substituted for a few days, and the 
treatment resumed after four or eight days. The cases got 
well in from ten to eleven weeks, without scars. 

Tuberculosis of the skin (both verrucosa and ulcerosa) may 
be treated with the actual cautery and with mercurial plaster; 
scrofuloderma (nodes in and under the skin of the face, neck, 
and extremities, with central softening and a cheesy pus), by 



DISEASES OF THE SKIN. 553 

arsenic internally and the sharp spoon, and subsequently iodo- 
form and balsam of Peru. 

Psoriasis, when acute, is a very distressing disease because 
of its intense itching. It requires many and protracted baths 
and plenty of soap to remove the scales; unguentum hydrar- 
gyri ammoniati is used for the same purpose. Ichthyol oint- 
ment (five to ten per cent.) has rendered me good service in 
the only case I have seen in a child for years. Beta-naphthol 
has been highly praised in ointments containing from five to 
ten per cent. Neisser recommends chrysarobin or anthrarobin 
ointments (five to ten to twenty per cent.). They are positively 
dangerous in such doses, when used on children, because of the 
extensive erythema and conjunctivitis following them. On the 
head, therefore, he substitutes pyrogallic acid, but it dyes the 
hair black and is not so efficient. For chronic cases the prin- 
ciple of treatment is the same. The eruptions must be at- 
tended to locally; ichthyol ointments will also do some good. 
Chrysarobin ointments (one to two per cent.), or chrysarobin in 
traumaticin in the same proportion, should be applied once 
every day or every few days. Green soap, or liquor potassii, a 
daily bath in soap and water, will dissolve the scales and facili- 
tate the effect of the other applications. Internally, iodides 
will prove effective in syphilitic cases. Thyreoid in small doses 
(1-2 grains = 0.06-0.125 daily) has had some successes among 
many failures. The best internal remedy is arsenic in long- 
continued moderate doses. 

A number of congenital diseases of the skin and subcutaneous 
tissue are amenable to treatment; to them belong the neo- 
plasms. Lipoma is found in two varieties: first, the circum- 
scribed and capsulated; second, the diffuse. While the former 
is as easily removed as in the adult, the latter is sometimes in- 
operable, inasmuch as it extends over large areas, and resembles 
in some instances, or in some parts of the anomalous growths, 
a moderate or formidable surplus of normal fat only. I had to 
give up an operation for removal before it was completed. Hard 



554 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

fibroma (connective tissue, circumscribed tumors) should be ex- 
tirpated before it gives rise to facial leontiasis or elephantiasis 
(Trendelenburg). Soft fibroma (f. molluscum Virchow, mostly- 
multiple, with a tendency to immense growth, sometimes pen- 
dulous, connective tissue with areolar structure) should be 
removed quickly from the cutis in which it develops. Keloid 
is a hypertrophied cicatrix extending upward from the corium, 
with rapid growth. Extirpation is useless because of the new 
development of keloid. Daily painting with liquor potassii 
arsenitis and ointments of sulpho-ichthyolate of ammonium 
in lanolin and fat aa 5-8 parts may be tried. Eepeated semi- 
weekly subcutaneous injections of a ten-per-cent. solution in 
absolute alcohol of thiosinamine (doses for adults grs. f-1^ == 
0.04-0.1) have been reoommended, as also for cicatricial con- 
tractures following lupus, etc. (Sinclair Tousey). Cysts and 
dermoid cysts are met with; many of them, though congenital, 
attract attention only after months or years. Atheromata (when 
small and superficial, embedded in skin only, — milia) are not 
infrequent about the head (eyebrows, etc.). They can be 
readily enucleated, and ought to be removed before they adhere 
to the skin and undergo suppuration. When they are sup- 
purating, and removal is very difficult or impossible, tartar 
emetic in water (1 : 30) may be injected, or hydrate of potas- 
sium introduced. Either of these will disintegrate the cyst wall 
to such an extent as to render their removal by pincers possible 
after a day or two. Congenital sarcoma has been described a 
few times, once by Neuhaus (Arch. f. Kinderh., vol. xxii., 1897), 
who collected a few other cases. They all commenced in the 
subcutaneous tissue. The only case beginning in the cutis itself 
was recorded by me for the Am. Pwd. Soc, 1897. It was on 
the upper part of the scrotum, with small metastases on the 
dorsum penis, and no swelling of lymph-bodies. It was excised, 
the metastatic deposits destroyed with the thermocauter, and 
the baby treated with arsenic. (Arch, of Ted., November, 
1897.) 



DISEASES OF THE SKIN. 555 

Congenital ichthyosis is the result of an exaggeration of the 
normally copious secretion of sebum during the second half of 
intrauterine life. Sebum not removed but thickened by epi- 
dermal cells and foreign material forms scales, which may be 
thrown off but are rapidly reproduced, and causes fissures and 
warts. This condition is not necessarily dangerous to life. A 
boy of fifteen was freed of his scales by a permanent warm bath 
of five days. Lanolin inunctions, with or without ichthyol 
(5-10 per cent.) will prove beneficial. Arsenic should be given 
internally. Thyreoid — with which, however, I have no experi- 
ence in this anomaly — might be tried. I should favor its use 
also in congenital idiopathic atrophy of the skin (head, face, 
hands, feet, nails, hair which is totally absent), which otherwise 
is not reached by treatment. The effect of thyreoid in myxoe- 
dema and its alopecia should encourage us. 

The worst forms of congenital ichthyosis, which terminate 
fatally in a few days, are not amenable to treatment. Partial, 
follicular ichthyosis, in which bony spina? grow out of hair- and 
tallow-follicles without affecting the general health, demands 
frequent bathing, green soap, plenty of fat inunctions, and a 
ten-per-cent. sulphur ointment. 

Congenital neoplasms on the neck are: hygromata (lymphan- 
giomata with albuminous contents and endothelia) ; serous and 
dermoid cysts, sometimes so dense as to render their diagno- 
sis from lymphatic tumors difficult when situated below and 
alongside the sterno-cleido-mastoid muscle; and sanguineous 
cysts, mostly diverticles of veins, or in a few cases rudimen- 
tary developments of the jugular vein. They require either 
enucleation or an extensive incision with aseptic tamponing. 

No3vus pigmentosus and verrucosus belong here. Their treat- 
ment is similar to that applicable to vascular nsevi and tumors 
(p. 373), the latter differing from the former by a greater 
prominence of the skin, which is produced by elongation of the 
papillae and by hyperplasia of connective tissue; also to the 
ncevus lipomatodes, which is a spherical or cylindrical fatty 



556 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

excrescence covered with normal skin, sometimes pedunculated, 
sometimes sessile and with a broad basis. A few of the latter 
class are liable to grow out of proportion; all the rest in con- 
formity with, or even less than, the rest of the body. In the 
majority of cases the time for an operative procedure is left to 
the medical attendant. Besides the methods of removal which 
have been detailed above, total extirpation is advisable in most 
cases. Indeed, it is the preferable method. Local anaesthesia 
can be easily accomplished by a mild solution of cocaine (grs. 
•J-2 : 100), or Schleich's solution, mentioned on page 78, in- 
jected into the skin. Excision is readily executed with but 
little loss of blood, and the sutured wound is covered with 
collodion. In a very few days, without a change of the collo- 
dion, recovery is apt to be complete. 



XII. 

DISEASES OF THE MUSCLES. 

Acute inflammation of the muscles — myositis — is located 
either in the external or internal perimysium, also in the con- 
tractile elements. Cellular infiltration, coagulation, fatty and 
hyaline degenerations, suppuration, nuclear proliferation, and 
the formation of new connective tissue are observed as its 
morphological changes, with either incurable retraction or 
curable contraction as their results. Traumatic myositis (see 
p. 99) requires absolute rest, the application of cold water or 
ice, after a while tincture of iodine once a day or every other 
day, iodide of potassium and lanolin ointment several times a 
day, or gentle massage without the ointment. Iodide of potas- 
sium internally is indicated when thickening remains behind. 
If, after a long time, the muscle, though without pain, does 
not become normal, the electrolytic effect of the galvanic and 
the stimulating action of the interrupted current, in short ses- 
sions, will improve the condition. Both traumatic and rheu- 
matic myositis have a tendency to relapses. The latter requires 
a treatment similar to that which has been detailed above, with 
this exception, that hot (dry) applications generally render 
better service, and the internal administration of salicylate of 
sodium is mostly indispensable. Inunctions of oil of winter- 
green are often useful, as are also diaphoretics. The infec- 
tious myositis of eruptive and septic fevers starts an effusion 
which is either serous or purulent, and requires accordingly, 
besides the active attention demanded by its origin, either ex- 
pectant or operative (and antiseptic) treatment. In those rare 
cases in which purpura is observed at the same time, the myo- 

557 



558 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

sitis has probably a hemorrhagic origin. Syphilis produces either 
gummata or hyperplasia, and demands, in addition to internal 
specific treatment, either the inunction of an oleate of mercury 
or of the blue ointment, or subcutaneous injections of the 
bichloride. Tubercular deposits are caseous and purulent; they 
must be incised, scraped out and irrigated, and the cavity filled 
with iodoform gauze. Purulent myositis is hardly ever idio- 
pathic, and its cause or complications must be ascertained 
(syphilis, tuberculosis, sepsis). 

The chronic forms of myositis met with in children are, as a 
rule, outgrowths of the acute inflammation. The rare forms of 
traumatic ossifying and that of petrifying myositis are hardly 
ever seen in childhood, with the exception of the occasional 
appearance of the multiple progressive ossifying variety, — a col- 
lateral to the cartilaginous exostoses, — which exhibits inflam- 
mation and bone-formation in the cellular tissue of the fasciae, 
in the aponeuroses, and in the tendons of the back, the chest, 
the masseter, and the extremities. Sometimes it is complicated 
with a defect or with ankylosis of the phalanges of the thumb. 
It is a nutritive disorder, always of congenital origin. No avail- 
able treatment is known. 

Ischemic muscular paralysis is the result of anaemia (mostly 
local, as from the influence of cold). The pain, loss of elas- 
ticity, and resulting contracture require massage, gymnastic 
exercise, and electricity, and the subcutaneous daily use of 
strychnine. 

Trophoneurotic ill nutrition and paralysis comprise two 
varieties. One is the result of inflammation of a joint: from 
disuse the neighboring muscles become atrophic and more or 
less paralyzed. The other originates in a change of the spinal 
centres, as in poliomyelitis, with fatty degeneration and 
atrophy as inevitable consequences. In both varieties sys- 
tematic massage of the paralyzed muscle, executed with ana- 
tomical knowledge, will do good, in the first with mostly com- 
plete success. Electrical treatment and strychnine may be 



DISEASES OF THE MUSCLES. 559 

combined with it. The atrophy is very rapid, with but slight 
changes of electrical irritability (no reaction of degeneration), 
and localized. If the knee be affected, it is the quadriceps that 
is suffering; if the hip-joint, the glutaei; if the shoulder, the 
deltoid, infraspinatus, and teres minor; if the elbow, the tri- 
ceps; if the wrist, the extensors of the forearm; if the fingers, 
the interossei. 

The "pseudo-paralysis" of rickety children is simply debility. 
Muscular atrophy, progressive juvenile muscular dystrophy, 
pseudo-hypertrophy, and congenital myotony have been men- 
tioned above (p. 315). 

The affection which has been described as grave pseudo- 
paralytic myasthenia, and which consists in a peculiar exhaus- 
tion of the muscles on slight exertion, to such an extent as to 
render voluntary contraction very difficult and to rapidly di- 
minish electrical excitability, appears to depend either on de- 
fective innervation or on chemical changes. In the single case 
I have seen, massage and strychnine rendered some service. 
Veratrine, physostigmine, and digitoxine are recommended. In 
neurasthenia the muscles are also unduly exhaustible, but from 
myasthenia it differs in this that the nerves are excitable. 

Torticollis (caput obstipum) means a contraction of the 
sterno-cleido-mastoid muscle, mostly its sternal end; the head 
is turned to the affected, the face to the opposite side, and the 
diseased side is not infrequently more or less atrophic. The 
treatment depends to a great extent on the cause of the con- 
traction. Spasmodic torticollis resulting from reflex of the sen- 
sitive nerves of the cervical plexus, requires the section of the 
latter. Malposition in the uterus is an occasional direct source, 
as also the hsematoma originating during birth, or later, which 
has been mentioned elsewhere (p. 98). Bilateral caput ob- 
stipum, with the result of forcing the head backward, has been 
observed in very young infants. In a case of Shaffer's the head 
was drawn forward. No blood was found in the muscles, but 
only firm connective tissue and atrophy of muscular fibres. 



560 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

This interstitial fibrous myositis depended, probably, on a num- 
ber of minute traumatic lesions during parturition. Tumors, 
such as sarcomata, have the same influence on the function of 
the muscle. This is impaired, in advanced childhood, by sud- 
den strains; for instance, by kite-flying, by loads carried on 
one shoulder, occasionally also by an abnormal position of the 
head enforced by paralysis of the ocular muscles, in order to 
avoid double vision (Landolt). Eheumatism of the muscle, 
isolated or more general, and of one or more vertebral articula- 
tions, and caries of the vertebrae have the same effect. Sali- 
cylate of sodium internally, oleum gaultherise, and ammoniacal 
or camphor inunctions will do good. The same may be said 
in regard to muscular rheumatism in general. Torticollis is 
also one of the symptoms of the acute rheumatism of the neck 
which, because of its serious symptoms (fever, vomiting, de- 
lirium, with no irregularity, however, of the pulse), has been 
mistaken for meningitis. Sometimes it depends on a neurosis 
(neuritis ?) of the accessory nerve. In that case the scalenus 
and trapezius muscles are also affected. Keflex torticollis has 
been mentioned in connection with intestinal worms and with 
carious teeth, and an intermittent form is known to exist 
(Forchheimer) and to depend on malaria. In these cases quinine 
and arsenic are indispensable. Worms must be removed, teeth 
corrected. A. J. Gillette says he cured a case by the removal 
of adenoid growths. In those cases in which heavy loads car- 
ried on one side cause contraction of the other, a systematic 
use of the diseased side will restore the equilibrium. Exag- 
gerated and forcible swinging of the arms will secure co-opera- 
tion and exercise of the muscles of the neck. Massage both of 
the muscles and of the articular processes of the cervical ver- 
tebrae from the third to the fifth is required. The galvanic 
current in mild doses relieves spasm. Gentle rubbing with 
lanolin (in inflammatory cases with iodide of potassium or mer- 
cury) is beneficial. Cold temperatures must be avoided. Other- 
wise unconquerable cases require tenotomy, to be performed 



DISEASES OF THE MUSCLES. 561 

by open incision, which protects the jugular vein better than 
the old operation from inside outward. When tenotomy is not 
sufficient, Mikulicz practises the total extirpation of the sterno- 
cleido-mastoid muscle. Too violent attempts at reduction may 
prove dangerous. Brackett (11th Meeting Amer. Orth. Ass., 
1897) met with alarming changes in pulse and respiration, 
which he attributed to adhesion and shortening of the pneumo- 
gastric nerve. 



XIII. 
DISEASES OF THE BONES AND JOINTS. 

1. Congenital Anomalies. 

Of the congenital malformations of the extremities (bones 
and soft parts), many are not accessible to treatment. To this 
class belong arrests of development and spontaneous amputa- 
tions. Curvatures of the limbs (congenital, through fracture of 
the tibia) may require osteotomy or osteoclasy; but their 
domain is not very extensive, for in the large majority of 
acquired rhachitical curvatures of the legs recovery takes place 
spontaneously. Observations in the surgical clinic of Tubin- 
gen, extending over a number of years, prove that seventy-five 
per cent, of all such curvatures will straighten out in from two 
to four years. When the patients were first presented, plaster- 
of -Paris casts of the deformity were made, and another ex- 
amination took place after an average of four and one-half 
years. Improvement was noticed in 15.3 per cent, additional. 
In 9.7 per cent, only no spontaneous recovery or improvement 
took place. It is in these that operations are demanded. Super- 
numerary fingers and toes are either removed from their cu- 
taneous attachments or extirpated from their sockets. Con- 
genital enlargements of toes, consisting in hypertrophy both of 
bone and fat, are removed by amputation. Universal giant 
growth is always congenital, but not hereditary. The connec- 
tive tissue, muscles, bones, and blood-vessels, all of which evolve 
out of the mesoderm, are equally affected. The nervous sys- 
tem and the joints are normal, the skin sometimes thickened, 
the nails correspond with the phalanges. Whether it is related 

562 



DISEASES OF THE BONES AND JOINTS. 563 

to akromegaly (which in its full development is observed in 
later years only, but may originate earlier) remains to be seen. 
For the present it is not amenable to treatment. Synechia of 
(webbed) fingers and toes must be separated; the operation be- 
ing difficult, it is best to delay it for some time, but not long 
enough to endanger the growth of the organ. Division of web 
with suture of the preserved skin on one finger and Thiersch's 
grafts on the other, or the latter on both fingers, is claimed to 
be the best treatment. 

Multiple infantile exostoses are congenital, sometimes heredi- 
tary, very rarely syphilitic, and then recognized by, or connected 
with, other symptoms of syphilis; they develop early, now and 
then only after puberty; grow near the periepiphyseal car- 
tilage, between epiphysis and diaphysis, sometimes from the 
very cartilage of the epiphysis; are now and then found on 
scapula, pelvis, and cranium; grow in rare instances even after 
the completion of the growth of the body; are now and then 
surrounded by a synovial membrane (exostosis bursata); re- 
main cartilaginous or become osseous, and then may interfere 
with the growth of the bones. They do not often disturb the 
functions of the long bones and joints, but the ulna has been 
known to become crippled by them, the skin may ulcerate over 
them, and the synovial capsule may be raised by one growing 
too near the joint. These complications require sometimes 
special treatment and attention. Exostoses, so long as they are 
but few and not cumbersome, are best left alone. However, in 
the next case of early age seen by me I shall give phosphorus 
(p. 141) systematically, for the purpose of enforcing speedy 
ossification, both local* and general. Extirpation is indicated 
when there are but few, and when these are large; under care- 
ful asepsis the operation is at present devoid of danger. Iodide 
of potassium has been administered extensively without ap- 
parent effect. When syphilis is suspected, mercury and iodides 
should be given a trial. 



564 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

2. Congenital Luxations. 

Congenital luxation of th& hip-joint, with the exception of 
rare cases depending on injuries contracted during birth, is the 
result of scantiness of liquor amnii, by which, in the cramped 
position of the fcetus, the growing femur is pushed out of the 
socket, or, in other (rarer) cases, of an arrest of development 
of the acetabulum, which is sometimes hereditary and now and 
then complicated with other malformations. The head of the 
femur finds no accommodation, and the trochanter is found 
above its normal place. This is particularly so on the steep os 
ilium of the female. When the luxation is unilateral the gait 
is limping; when bilateral, waddling. Extension lengthens 
the extremity and conceals the deformity. Treatment is either 
mechanical or operative. Until a few years ago the mechanical 
treatment was the only one generally recommended. Volk- 
mann relied on permanent extension, particularly in unilateral 
cases. Hessing has good results with his apparatuses. Schede 
uses splints, with pelvic support, to extend and to abduct the 
extremity, for from two to four years in succession. He finds 
the indication for this treatment in bilateral cases up to the 
fourth year, in unilateral cases up to the eighth or ninth, for 
the rudiment of the acetabulum whose size can be improved 
upon frequently persists up to that period of life. Paci lost 
a girl of seven years by dysentery four months after re- 
duction and extension of her bilateral dislocation; he found at 
the autopsy two new joints which appeared to promise stability 
of the femoral head in the new position, if the child had lived. 
Within a short time the results of operations have become very 
favorable. At the Congress of German Surgeons of 1894, 
Lorenz — in that of 1895, Hoffa — presented very satisfactory 
statistics and patients. Neither of them cuts the muscles, but 
both reduce the dislocated limb by powerful extension. Hoffa's 
incision is longitudinal, like tha,t made for resection (Langen- 
beck); the capsule and soft parts are loosened from the trochan- 



DISEASES OF THE BONES AND JOINTS. 565 

ter by subperiosteal operation, the acetabulum is enlarged and 
the head fitted into it. The superfluous capsular tissues are 
then extirpated, the wound is filled with iodoform gauze, and 
an extension apparatus applied. The extremity begins to 
grow, shortening becomes less, and head and acetabulum grad- 
ually increase in size. Hoffa's operations were performed be- 
tween the second and eighth years. He presented the statistics 
of one hundred and twelve operations performed on eighty-two 
patients without cutting muscles. The last forty-seven termi- 
nated without a death. Lorenz's incision runs anteriorly; he 
does not touch the insertion of the muscles. 

Lately, A. Lorenz* has published his objections to the pro- 
tracted employment of extension, which keeps the patient in a 
recumbent position, possibly for years, and interferes with the 
nutrition and function of the limb or limbs. Instead, he ex- 
tends forcibly, under anaesthesia, and reduces the head of the 
femur, the reposition being kept up by strong abduction. The 
head of the femur is then retained in the small acetabulum by 
apparatuses and the abduction is gradually diminished. After 
a while standing and walking are permitted. At first, while 
abduction is continued, these movements are clumsy and dif- 
ficult, but when the weight of the body and the constant 
friction have deepened the acetabulum, they become easier by 
degrees. The oldest child in whose case this procedure was 
successful, the luxation being bilateral, was six years and 
three months. In one case of unilateral luxation, standing 
and walking were interrupted three days only, in others sev- 
eral weeks. Even when the luxation was bilateral they were 
not long delayed. Two patients were able to stand in six weeks. 
To ascertain the actual result of a successful reduction, the 
X-rays have been employed before and after the treatment. As 
a result of more mature experience, public opinion among sur- 

* Centralblatt f. Chir., 1895, No. 33; Samml. klin. Vortr., 1896, Nos. 
150, 151. 



566 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

geons is swinging back to mechanical treatment almost exclu- 
sively. Schede, Hoffa, Lorenz, Wolf, and Kiimmell (Assoc, of 
Germ. Pliys. and Nat., 1896) unanimously discredit any bloody 
operation in the treatment of even severe cases. It should be 
resorted to as a last resource, and promises no success, but is 
risky. Schede reported ninety-nine cases of infants and children 
up to fifteen years of age, ninety-eight of which recovered with 
manipulation only. Lorenz reported eighty-three cases treated 
by manipulation, and extension in abduction, successfully. 
(A. H. Tubby, London Lancet, May 1, 1897.) The advantages 
of mechanical treatment are its simplicity and the avoidance 
of the danger connected with every great operation, of scars, 
and of probable contractions in later life. 

Congenital luxation in the knee-joint is not so frequently ob- 
served as that in the hip-joint. Still, G. Muskat collected (Arch. 
Jclin. Chir., vol. liv.) seven genuine luxations, four contractures 
in flexion, and seventy-one incomplete luxations. Massage, 
cautious attempts at restoring motility, and — under the most 
urgent circumstances only — the opening of the joint are recom- 
mended. 

Congenital dislocation of the shoulder was observed in rare 
instances as the result of trauma during parturition. F. S. Eve 
(London Lancet, May 1, 1897) describes two cases. The head 
in one was below the spine of the scapula. In the other the 
joint was found "normal, the head elongated, obliquely back- 
ward." Eedundant cartilage was shaved off, and reduction 
performed. 

3. The Bones. 

Fractures heal the more readily the younger the patient. 
Callus is speedily formed, and, the muscles being feeble, dis- 
location of the ends of the bones does not take place to any 
considerable extent. Elixir of phosphorus in increasing doses 
will hasten consolidation in the feeble and anaemic. The frac- 
ture of the humerus occasioned during birth requires a light 
splint with but little wadding. A piece of pasteboard and a 



DISEASES OF THE BOXES AND JOINTS. 567 

few strips of adhesive plaster or a bandage, and the support of 
the limb by fastening it to the body, are sufficient. Clavicles 
heal readily when tied up in a triangular cloth, the arm being 
fastened to the body. Where moistening by urine, etc., is 
feared, the bandages should be painted with a solution of resina 
dammar in ether (1 : 10). 

Perichondritis and osteochondritis occur, of course, in earliest 
infancy only, mostly under the influence either of rhachitis or 
of syphilis, most frequently in the forearm and the leg, also 
on the ribs or clavicles, and terminate either in cutaneous in- 
filtration or disruption of epiphyses. Pain is rare, and the 
"pseudo-paralysis" of Parrot means but the functional dis- 
turbance due to infiltration of the tissues. Periostitis, ostitis, 
and osteomyelitis are due, in the first instance, to the disposition 
created by the activity of metamorphosis and by the physio- 
logical succulence of the bones, whose growth starts from the 
periosteum, from the marrow, and from the periepiphyseal car- 
tilage. The vulnerability of general scrofula and hereditary 
influences add to their liability to become diseased. Proximate 
causes of inflammation are trauma, colds, infectious diseases 
such as whooping-cough and measles, and the invasion of 
cocci and bacilli through umbilicus, mouth, tonsils, or any 
other sore surface, with the resulting septicopyemia. The ter- 
mination of periostitis is either in absorption, or thickening, or 
suppuration. In "albuminous periostitis" pus is substituted by 
serum and fat. In scrofulous and tuberculous children ostitis 
is mostly found in the short bones and in the epiphyses. The 
bones swell, become softened (porotic), in their interior sup- 
puration loosens the tissue and dilates the medullary spaces so 
as to inflate and expand the thin external layer (spina ventosa). 
Tubercular ostitis softens the bones into a yellowish caseous or 
fungous mass, and thereby forms cavities, which may heal by 
means of absorption of the liquid contents and calcification of 
the remnant, but mostly end in caries or necrosis, in sinuses, in 
persistent suppuration, and not rarely in amyloid degeneration. 



568 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

The degrees of the different forms vary considerably. For in- 
stance, necrosis may be superficial, with a favorable prognosis; 
or central, with the formation of a sequestrum the removal of 
which incites granulations and new formation of bone; or total, 
and thus removes whole bones, such as the calcaneous, the 
cuboid, entire phalanges, or the diaphysis of the long bones. 

The prognosis is best when the process is superficial. Ab- 
solute rest, elevation of the limb, cold applications, tincture of 
iodine, and deep incision in case of very severe pain which be- 
trays the presence of pus comprise the proper treatment of an 
acute periostitis. Chronic thickening will usually be reduced, 
perhaps even removed, by moderate pressure, iodide of potas- 
sium internally, and (or) an ointment of the same with lanolin. 
Syphilitic periostitis requires iodide of potassium in increasing 
doses, occasionally combined with mercury. Ostitis and osteo- 
myelitis (deep, agonizing pain, with but little swelling at first) 
require a treatment similar to that of periostitis. The bone 
should be kept at rest, well elevated and supported by splints, 
and ice applied. In mild and slow cases tincture of iodine, or 
the ignipuncture of Kocher, will yield favorable results. 
Syphilis demands its specific treatment no matter where met 
with. It should be remembered, that syphilitic dactylitis, in 
the shape of spina ventosa, cannot be diagnosticated, clinically, 
from the tuberculous form; also that syphilis and tuberculosis 
may be found in the same baby. In suoh cases a protracted 
antisyphilitic treatment is indispensable. Incision may strike 
an abscess, which is then drained. A sequestrum is removed, 
and will be replaced by bone as long as there is no dangerous 
general affection. Antiseptic irrigations are indicated in most 
of these cases, and antiseptic applications should be made con- 
stantly if gauzes are not used to fill a cavity or sinus. When 
caseous degeneration has taken place to a great extent, the 
question of mere scraping or of resection presents itself. Osteo- 
myelitis requires an early operation, sometimes within a few 
days after the appearance of the first symptoms. Esmarch's 



DISEASES OF THE BOXES AND JOINTS. 569 

bandage, the chisel, and the sharp spoon are the main reliances 
of the surgeon; the seat of the disease must be reached and 
entirely uncovered; counter-openings and ample tamponing 
may be demanded. Spina ventosa should be treated in a similar 
manner; part of the remaining external osseous layer should 
be removed and the cavity filled with iodoform or other anti- 
septic gauze. Obstinate sinuses must be repeatedly scraped. 
They often heal under a carefully conducted Bier's treatment 
(p. 576), with parenchymatous injections into the surrounding 
tissue, not into the sinus itself, of an iodoform emulsion. 

In every case of this kind — in fact, in every case of subacute 
or chronic inflammation of the osseous tissue — phosphorus 
ought to be given. It may be continued in such doses as are 
recommended elsewhere (p. 141) for two or three months in 
succession. 

Tuberculosis of the body of a vertebra (more frequent than 
that of the arch or of a process) underlies spondylitis in almost 
every case. The intervertebral cartilages are but secondarily 
affected. In many cases a trauma is charged with being the 
proximate cause, in others the process develops spontaneously, 
with but few symptoms. Stiffness on moving, pain on moving 
and pressure, very little, if any, increase of temperature, inabil- 
ity to bend and rise without support on a knee or some near 
solid object, are quite often the persistent, but only, symptoms. 
When spondylitis is cervical, it is liable to produce headache, 
dyspnoea, and retropharyngeal abscess; when lumbar, pain in 
the thigh or symptoms resembling those of coxitis. Usually 
there is already pus either in the bone or at some distance from 
it. It finds its way along the fascia, rarely into the vertebral 
canal, and is met with in the lumbar and gluteal region, in the 
small pelvis, along the psoas and internal iliac muscles, and 
along the rectum. The latter occurrence is unfavorable be- 
cause of the slowness — if at all — of recovery. Lumbar and 
gluteal abscesses are more readily discovered than those of the 
psoas, and therefore more amenable to treatment. Incision, 



570 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

wiping out with aseptic gauze (better than irrigations) and in- 
jection of a five-per-cent. iodoform-glycerin emulsion, will lead 
to recovery, provided the suppurating and tubercular vertebra 
healed out. Even psoas abscesses close up in that way, after 
the destruction of the pyogenous membrane. As far as the 
spondylitis is concerned, there is unfortunately, rarely a re- 
covery without some deformity, but if treated in time and 
properly (corset with or without jury-mast), recovery may take 
place without it. Permanent gib bus should be avoided. Cases 
with much suppuration exhibit lasting and marked kyphosis 
(Pott's disease) or scoliosis, or kypho-scoliosis. As soon as the 
diagnosis can be made, the patient must remain on his mattress, 
with a moderate amount of extension. Ice will relieve local 
pain. When it is moderate, tincture of iodine will answer. 
Hueter recommended the subcutaneous injection of a two-per- 
cent, solution of carbolic acid. When there is no fever, the 
time for a plaster-of-Paris jacket, according to Sayre, has ar- 
rived. What the latter requires, however, is that the child 
should not be too young. To be useful, a certain length of the 
spine is necessary for its application. Thus, it is principally 
in the dorsal spondylitis of children of a certain age that it 
exhibits its best results. The jury-mast is added to support the 
head and thereby to reduce local pressure in cervical cases. 
Abscesses gravitating downward are better not touched before 
they reach the surface. Then, before their spontaneous per- 
foration, antiseptic irrigations and the use of iodoform emul- 
sions are indicated. 

Most cases of spondylitis are tubercular. Abscesses are fre- 
quent and difficult to diagnosticate. The disease is dangerous 
because of its origin, and its effect. Preventive treatment is 
always indicated, and mechanical treatment should be gentle. 
Calot's method of rapid reduction with or without removal of 
spinous processes (thirty times in thirty-seven cases) has natu- 
rally resulted in several deaths. The author's intrepidity and 
his disrespect both of human life and of public opinion is won- 



DISEASES OF THE BONES AND JOINTS. 571 

derful to behold. His "method" would concern less the forum 
of medical than of criminal courts, but for the later modifica- 
tion of his original violent procedures. 

A number of cases described as chronic articular rheumatism 
are undoubtedly those of arthritis deformans. The differen- 
tial diagnosis is perhaps best made by remembering that the 
term "rheumatism" is still too vague to allow its use for diag- 
nostic purposes. The only condition which deserves it is acute 
(or subacute) articular rheumatism, rheumatic polyarthritis. 
It affects the synovial membranes. Gout (the affection has also 
been called "rheumatoid gout") requires uratic deposits. Ar- 
thritis deformans is an affection of the cartilage (influenced 
by anomalies in the bones ?), first, proliferation between the 
intercellular fibrilla3, then absorption, with, finally, hyperplastic 
eburnation around the absorbed cartilage and distortion of the 
limb (the hand in the ulnar direction mostly, with intact thumb 
and thoroughly enlarged phalangeal ends). A similar process 
takes place about the shoulder, elbow, knee, toes, and vertebrae. 
Marked cases such as I have seen myself have lately been pub- 
lished by A. G. Nichols (Montreal Med. Journ., 1896), H. 
Koplik (Arch. Ped., 1896), who collected eighteen, and Vargas 
(Bull. ofpc. de Barcelona, April, 1897. He counts "Jacobi 
among those who do not mention the disease," erroneously). 
Very suggestive are also the early changes which take place in 
the skin and the rest of the epidermoid tissues and in the mus- 
cles. The accompanying changes in the muscles, — a slowly pro- 
gressive atrophy with corresponding paralysis, without reaction 
of degeneration, and with only so much alteration of electrical 
and galvanic excitability as is explained by the atrophy of the 
muscular tissue, — trophic changes of the nails of fingers and 
toes (thickening, fragilit}^ and exfoliation), and those of the 
skin (vitiligo and chloasma and slight indications of sclero- 
derma, even ichthyosis in a few instances*) appear to prove 

* Curschmann in Schmidt's Jahrb., 1895, No. 8, p. 220. 



572 THERAPEUTICS OE INFANCY AND CHILDHOOD. 

their great difference from rheumatism and their very intimate 
connection with the nervous system, which is known to influ- 
ence greatly both bones and joints (S. Weir Mitchell, Clin. 
Less, on New. Bis., 1897). Consequently the antirheumatic 
treatment, by salicylates, etc., is absolutely useless. The gal- 
vanic current, slowly increasing doses of arsenic administered a 
long time, and judicious massage have served me best. Ar- 
thritis deformans is not incurable. 

4. The Joints. 

Inflammations of the joints are frequent, — more so in infancy 
than in childhood. Acute cases are rare, however, in children 
eight or ten years old, who have more control over their muscles 
and take better care of themselves. Younger children are more 
exposed to traumatic injuries; besides, not to speak of the 
phlebitis of the newly-born, there are in the earlier years dis- 
tinct predisposing causes of joint-disease in such infectious 
diseases as scarlatina and diphtheria. Syphilitic joint-diseases 
appear in infancy and childhood in different forms, as epiph- 
ysis with effusion into the joint without synovitis and with- 
out suppuration; as ostitis with effusion and with gummatous 
infiltration of synovial membranes and effusion; as primary 
gummatous synovitis (rarely); as symmetrical synovitis (mostly 
in the knees) in children of from eight to fifteen years, at the 
same period of life in which the interstitial keratitis of syphilis 
is commonly found. In all of these affections a thorough and 
protracted antisyphilitic treatment is required. In all joint- 
diseases the synovial membrane, the fibrous capsule, and the 
cartilage are affected either separately or collectively, and the 
contents of the diseased cavity are either serous, or purulent, 
or fungous. Most of the latter are tubercular, and were known 
to be so long before the tubercle bacillus was discovered. In- 
deed, as early as 1873, Koster recognized the tubercular nature 
of "tumor albus." 

The prognosis is fair when the secretion is serous. Fluctua- 



DISEASES OF THE BOXES AND JOINTS. 573 

tion is easily recognized when the joint is superficial. It re- 
mains as "hydrarthros" in chronic cases. The treatment re- 
quires absolute rest, and in the acute stage the flexed position 
of the limb — which is either voluntarily chosen because it re- 
lieves tension, or is the result of a reflex contraction — must 
be respected. Other aids are: cold applications and mustard 
plasters; in less urgent cases, tincture of iodine, pure or diluted 
with alcohol, once or twice daily; in chronic cases, a vesicatory 
either to its full effect or applied for half an hour only, and 
repeated daily or several times a day; later, ointments of iodide 
of potassium and lanolin, or mercurial plaster, which may be 
made to cover the whole joint and may be changed once every 
few days; two daily applications of iodoform in collodion 
(1 : 8-20) over the whole joint; and compression, with a rub- 
ber bandage over a proper pasteboard, felt, or wood splint, the 
latter to protect the neighboring large blood-vessels. Iodide 
of potassium internally will render good service while the affec- 
tion is of a purely inflammatory character. Persistent contrac- 
ture must be overcome by massage, cautious passive movements 
as long as there is no pain, and forcible extension, either with- 
out or with anaesthesia. Massage improves the prognosis in 
subacute serous inflammation of the joints, also in contusions 
and distortions; after the massage the joint should be immo- 
bilized, slightly compressed, and raised. It acts well in chronic 
(rheumatic) inflammation, with thickening and proliferation 
of the capsule. Villous proliferations should be broken up by 
manipulation and changed into a detritus. 

Tubercular cases have a decided tendency towards either 
suppuration or fungous degeneration. About the knee the ab- 
scess is often outside the capsule and permits of an incision 
which does not reach the interior. Still, a small communica- 
tion with the latter is almost always present. Intracapsular 
abscesses, the opening of which was once so dangerous as to be 
considered semi-criminal, are no longer the bugbear of surgery. 
Repeated aspirations of the pus under aseptic precautions with 



574 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

subsequent injection of sterilized iodoform in oil or glycerin 
(1 : 5-10), or in liquefied vaseline, and intra-articular occasional 
operations, such as scooping, resection, etc., with, tamponing 
and draining, have reduced the dangers and are daily swelling 
the records of recoveries. General treatment to overcome the 
anaemic and cachectic condition, and particularly antitubercu- 
lar hygiene and medication, are demanded in most cases. 

Lately {Deutsche Zeitsch. f. Chirurgie, vol. xli., July 30, 1895, 
p. 378), E. Wieland published a contribution to the treatment 
of surgical tuberculosis in childhood with iodoform injections 
which, to my mind, contains everything now known on the 
subject and all that is sound and advisable. Iodoform treat- 
ment, however, is certainly not a panacea. Cases of tubercular 
coxitis, for instance, complicated with large abscesses and with 
perforation of the acetabulum, which offer great difficulties in 
the way of irrigation, of thorough cleaning out, of injections, 
and of compression, are liable as well to resist iodoform treat- 
ment as to yield unfavorable results after a radical operative 
interference. But in a large percentage of cases injections of 
iodoform emulsions, aided by orthopaedic measures (bandages, 
stays, plaster of Paris) or by mild operative procedures, and last, 
but by no means least, by constant attention to the general 
health (air, food, clothing, and bathing), and by medicinal sup- 
port with arsenic, creosote, or, preferably, guaiacol, yield good 
results. It is true, this treatment takes patience and time, is 
even apt to be expensive, and certainly exhibits no tangible 
proof of a great surgical achievement to the impressionable lay 
mind; but it is efficient, and has the advantage of not inter- 
fering with the growth and development of the limbs, which 
are mostly injured, and permanently so, by subjecting the epi- 
physeal cartilages to a radical operation. In a few cases the 
absorption of iodoform, when employed in solutions, has proved 
dangerous through a consequent toxic nephritis. For this rea- 
son, solutions in ether or oil are not to be recommended; for, 
after all, it is the local effect of iodoform which is aimed at, 



DISEASES OF THE BONES AND JOINTS. 575 

and not a general one. Emulsions are preferable. Krause 
employs a suspension of ten per cent, of iodoform in water, 
with the addition of but little glycerin and gum-arabic. 

The places to be selected for injections, according to him, 
are, — for the wrist-joint, below the styloid process of the ulna; 
for the elbow, above the capitulum radii; for the shoulder, 
exteriorly to the coracoid process: for the hip, above the tro- 
chanter major; for the knee, below the patella; for the ankle- 
joint, below the malleolus, in an upward direction. The 
injection into the hip-joint is made, according to Kiister, who 
has followed that method these nearly ten years, at the interior 
margin of the sartorius muscle on a line drawn between the 
crossing of the femoral artery and the prominence of the tro- 
chanter major. That is where, in lean persons, the spherical 
head of the femur is liable to be felt, and where in coxitis visi- 
ble or palpable swellings are not uncommon. For at this point 
the capsule is thinnest, and here, also, is the location of the 
subiliac bursa which in ten per cent, of the cases communicates 
with the joint. As a trocar may hurt the cartilage, a hypo- 
dermic syringe is employed, the canula of which has a length 
of from five to seven centimetres and a thickness of one milli- 
meter. Kiister does not irrigate the joint, because in a large 
proportion of the cases there is either no fluid at all (paren- 
chymatous synovial tuberculosis), or when present it is either 
sero-fibrinous (hydrops tuberculosus) or purulent (cold abscess). 
Neither Bruns nor Kiister believe that an irrigation with a 
three-per-cent. solution of boracic acid, or another antiseptic, 
has any better effect than the uncombined injection of iodo- 
form. In the parenchymatous variety from five to ten cubic 
centimetres (1-2 J fluidrachms) of a mixture of twenty per 
cent, of iodoform and eighty of glycerin are employed; this 
operation is performed weekly (Bruns). In the serous or puru- 
lent variety, after the fluid is either aspirated or spontaneously 
discharged, from ten to thirty cubic centimetres, enough to 
moderately fill the cavity (2-| fluidrachms to 1 fluidounce), are 



576 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

injected. This procedure is repeated every two or four weeks 
(0. v. Biingner, Centralb. f. Chir., No. 51, 1892, pp. 1057-1064). 
Periarticular abscesses should be incised and scraped thor^ 
oughly before an injection is made. The same holds good for 
fungous degeneration of the capsule of a joint. Bones in a very 
diseased condition — the talus, for instance — should be removed 
entire. If pus cannot be removed thoroughly, counter-openings 
are required. At first, for the purpose of thorough cleansing 
and disinfection, irrigations may be made with a mild solution 
of bichloride of mercury (1 : 5000), to be followed for a few 
moments by a stronger one (1 : 1000-2000). The principle of 
conservatism must never be lost sight of. All surgeons are 
unanimous at present that conservative treatment is the more 
urgently demanded the younger the patient. Eadical opera- 
tions are indicated only when the case is one of extensive and 
protracted irremediable suppuration with progressive destruc- 
tion of tissue. Eesection, however, must not go beyond the 
cartilage between epiphysis and diaphysis. If tuberculosis be 
markedly developed, either locally or generally, it is better to 
amputate than to resect. Fistulas which do not contract or 
shorten should be treated with strips of gauze dipped in equal 
parts of balsam of Peru and alcohol, and when they are very dry 
and indolent, with (Villate's) injections composed of sulphate of 
copper 10 parts, sulphate of zinc 10 parts, and distilled water 
120 parts. It is particularly the knee- and elbow- joints that 
require conservative treatment, both cautiously and patiently. 
Another method of conservative treatment of tubercular 
joints has been introduced by A. Bier (Arch. f. Iclin. Chir., 
1894, p. 306). Encouraged by the fact that lungs in a condi- 
tion of passive hyperemia resulting from cardiac disease or 
from kyphosis have a rather pronounced immunity from tuber- 
culosis, he advises to produce a passive venous congestion of the 
tubercular joints by bandaging the limb tightly below the 
affected joint and compressing it above with an india-rubber 
band (Esmarch). To secure a moderate amount of hyperemia 



DISEASES OF THE BOXES AND JOINTS. 577 

and cyanosis, and to avoid undue pressure and oedema, the 
bandaging should be gentle, and be interrupted once or twice a 
day. Such a degree of passive hyperemia is known to give rise 
to the new formation of connective tissue and to induration. 
This, it is suggested, affords a certain degree of protection 
against the proliferation and action of bacilli. This is also 
the effect aimed at by Landerer when he recommends cin- 
namylic acid, and by Lannelongue, who injects chloride of 
zinc for that purpose. That such was Koch's theory when he 
introduced tuberculin is well known. 

It is only very docile children that submit to the treatment 
readily. That is why days should be spent on playwise appli- 
cation of the method and on gaining the good will and the 
confidence of the patient. Bier continues his treatment at 
least three months. Massage, formerly used simultaneously, 
he has discarded. He found his method particularly practical 
when employed for tuberculosis about the ankle-, knee-, and 
elbow-joints, also for the testis, less so for the shoulder, not at 
all as yet for the hip-joint. He found, however, that if there 
was much suppuration, the limbs thus obstructed tended now 
and then to acute inflammation, lymphangitis, or erysipelas. 
Ulcerations increased in size, but finally healed; sometimes 
large granulations sprang up, but recovery took place eventu- 
ally. Tubercular sequestra were often absorbed, and sometimes 
firmly attached to and embedded in the surrounding osseous 
tissue. Even tubercular skin was benefited by frequent dry 
cupping, but not to such an extent as joints and bones by the 
above treatment. Glands were not accessible to the same 
method, except the cubital. Sarcoma, lupus, and syphilitic 
swellings were rather the worse for it; so was extensive sup- 
puration with streptococci and staphylococci. In acute rheu- 
matism the effects varied; in gonorrhceal joints, chronic articu- 
lar rheumatism, and arthritis deformans they were fair. If 
carried out with care and perseverance, Biers method yields 
sometimes astonishing results. (See Willy Meyer's report be- 

37 



578 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

fore Orthop. Section of the N. Y. Acad. Med., Americ. Med. 
Surg. Bull, 1895). 

The treatment, however, is not always to be confined to this 
method alone. Abscesses are aspirated, if possible, in their 
upper part to avoid persistent discharge, and filled with a ten- 
per-cent. iodoform emulsion. Slight compression may follow, 
and the injection is repeated in about a week. If there be con- 
siderable purulent discharge, the iodoform treatment is con- 
tinued or Villate's solution (p. 576) employed. Under its use 
bone fistula? heal rapidly. If loose splinters be accessible, they 
are removed. Forcible extension by apparatuses under anaes- 
thesia, tenotomy, and plaster of Paris should be employed in 
the treatment when indicated; so should passive movement, 
massage, and warm baths, particularly where there is func- 
tional ankylosis. True ankylosis requires resection when the 
false position of the extremity becomes intolerable, for a con- 
siderable curvature of the lower extremity or the extension 
or hyperextension of the upper cannot be borne. That gener- 
ous diet and proper hygiene and antiscrofulous and antituber- 
cular medication must not be omitted in an ailment which 
either is the result or may be the beginning of a generalized 
infection is self-evident. The best results of the treatment of 
tubercular bones may be expected in the calcaneus; its ante- 
rior portion is mostly affected because its spongious part has 
a scanty circulation only and its medullary part is large and 
soft. For the same reason sequestra may be found, which are 
rare in the other bones of the tarsus. As it is least connected 
with other bones, its tuberculosis remains mostly local, but may 
affect the adjacent tendons (Finotti). 

So far as the antitubercular treatment with guaiacol is con- 
cerned, I can but repeat what I said on the subject formerly. 
No one treatment of all forms of tuberculosis ever satisfied me 
to the same degree as has that with guaiacol. In the different 
varieties of pulmonary tuberculosis, when the destructive pro- 
cess was not too acute, it has almost invariably improved both 



DISEASES OF THE BOXES AND JOINTS. 579 

appetite and general condition, rendered expectoration less 
purulent, and increased the weight of the body as well as it im- 
proved the complexion. The more chronic the cases the more 
perceptible is the effect of guaiacol. Thus, in tuberculosis of 
the osseous system its action is very satisfactory. The dose for 
a small child is from a drop to two or more drops, to be re- 
peated three or four times a day, or the carbonate of guaiacol 
in three or four daily doses of from one to three or four grains 
each. Both of these preparations, particularly the latter, may 
be combined with other drugs, according to indications, — 
preferably with arsenic in generalized tuberculosis of the soft 
tissues, or with phosphorus in extensive inflammations of the 
bones of a chronic or subacute nature. 

Coxitis begins mostly in the head of the femur, and is rarely 
attended with very acute symptoms. As it is curable when 
recognized early, every case of dragging, of untimely fatigue, 
of favoring either limb, of vague pain, and of slight increase 
of body temperature in the afternoon requires careful and re- 
peated examination. Pain in the knee depending on irritation 
of the obturatorius and internal saphenous nerves is not in- 
creased by pressure. Limping and apparent lengthening of 
the limb with abduction and shortening with adduction are 
found not to be actual, but the result of voluntary change of 
position. These conditions are overcome by rest, the local 
applications mentioned above, and conscientious extension in 
bed. At a later period, when all the symptoms of acute irrita- 
tion have disappeared, extension by apparatuses and counter- 
extension may be employed for the purpose of permitting 
active exercise (Taylors and Phelps's extension splints). TThen, 
however, the swelling increases, an abscess is formed, and per- 
foration takes place, a spontaneous luxation will often be the 
result, with either elongation or shortening (luxation upward 
and backward with adduction and inward rotation of the ex- 
tremity). The os ilium may perforate, or what is left of the 
head of the femur may start for the sciatic foramen, or upward, 



580 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

and all of the head may be lost by suppuration. Even in these 
bad cases partial recovery takes place sometimes. A new joint 
may be formed or actual ankylosis result from the healing 
surfaces joining each other. The size of the incisions will de- 
pend on that of the abscesses, and the operations on the bones 
on their condition. Complete resections ought to be made in as 
few instances as possible; the periepiphyseal cartilages con- 
trolling the growth of the limb require careful protection. 

Tubercular coxitis is eminently a disease of early age. Nearly 
fifty per cent, of the cases occur during the first decade of life, 
nearly forty during the second. One-third of all the cases re- 
main free of suppuration; of these, seventy-seven per cent, get 
well; of the purulent form only forty-two. Altogether, about 
forty per cent, terminate fatally, death ensuing from tubercu- 
losis of the lungs or of the meninges, or from general miliary 
tuberculosis, amyloid degeneration, or exhaustion by suppura- 
tion or by sepsis. About fifty-five per cent, get well under con- 
servative treatment; still, the motility of the hip-joint is im- 
paired by contraction, so that either adduction (in two-thirds 
of the cases) or abduction, with actual or apparent shortening 
or lengthening of the extremity, results therefrom. Actual 
shortening depends either on retarded growth or (in the process 
of bone destruction) on displacement of the acetabulum, which 
is more frequent than spontaneous luxation; apparent shorten- 
ing results from the voluntary elevation of the hip, or by 
fixing the extremity in adduction parallel to its fellow. 

The general rules of constitutional and local treatment hold 
good for gonitis (inflammation of the knee-joint), which is 
liable to be tubercular in perhaps a larger percentage than any 
other joint. Deformity becomes very marked at an early date, 
the leg is very apt to be luxated backward, rotated outward 
and in genu valgum position, and both pseudo-ankylosis (ad- 
hesion of the ends of the bones by connective tissue) and true 
ankylosis (solid connection of the cartilages or of the bones) 
are frequent. 



DISEASES OF THE BONES AND JOINTS. 581 

Inflammations of the ankle- and tarsal- joints are mostly tu- 
bercular. They take a slow course in most instances, and result 
but rarely in recovery unattended by deformity, unless there 
be timely, either conservative, or operative, or combined treat- 
ment, which may save many a foot and life. Unfortunately, 
constitutional tuberculosis is a frequent complication, and 
death, therefore, is not uncommon before even a local restitu- 
tion can take place. The elbow-joint exhibits the same ten- 
dency to deformity and ankylosis, but is rarely the source of a 
hectic condition and of death. Early fixation in a sling and the 
application of either water-glass or plaster-of-Paris bandages 
are indispensable, while the forearm and the humerus should 
be placed nearly rectangularly. The same position must be 
secured for the foot. In coxitis and gonitis the limb ought to 
be kept entirely or nearly straight. 

Genu valgum {knock-knee) is the exaggeration of a normal 
disposition produced by a slight depression of the external parts 
of the articular surface, mainly of the thigh. This disposition 
is increased by the rhachitical softening of the bone (in later 
life to an eminent degree by the pressure brought about by 
the occupation of bakers, waiters, saleswomen, etc.). The 
speedy cure of rhachitis is an essential preventive. A plaster- 
of-Paris support (which ought to be renewed every few weeks), 
made to dry while the extremity is gently flexed, procures a 
normal position while the bone is hardening under the in- 
fluence of phosphorus, etc. The elastic length-garters, which 
have to a great extent taken the place of the circular ones, ap- 
plied below or above the knee, must not be tense, for in that 
case they increase the external concavity. They ought to be 
worn on the inside of the thighs, or both inside and outside. 
In bad and chronic cases osteotomy is performed above the 
condyle of the femur (McEwen), also on the diaphysis of the 
tibia, and the bones are then allowed to heal in extension. 
Genu varum is almost always the result of a rhachitical out- 
ward curvature of (and below) the epiphysis of the tibia. It is 



582 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

but rarely that the femur participates in the deformity. If it 
be noticed in time, straightening can be effected before the 
parts harden. After this has taken place, osteotomy or osteo- 
clasy must be resorted to. 

Pes varus {club-foot) is often congenital. Defective supina- 
tion is normal in the foetus, and becomes exaggerated by the 
pressure of the uterus when amniotic liquor is scanty. In 
many cases there is at birth a deformity of the talus of such a 
character that its neck is long externally and the head turned 
inward; also of the calcaneus, whose anterior process is raised 
and articulations somewhat dislodged. According to H. von 
Meyer, the posterior tibial muscle is always primarily affected. 
The paralytic variety of club-foot results from immobility of 
the extremity, caused by complete paralysis or by some other 
sickness necessitating protracted rest in bed, or from paralysis 
of the extensor muscles of the lower extremities consequent 
on poliomyelitis. The deformity is rather an equino-varus 
than a mere varus. With proper timely precaution its develop- 
ment may be avoided. 

As the articulations begin to suffer at a very early period, 
and growth is very rapid, treatment should begin at once. In- 
deed, the foot which at birth is seventy-five millimetres in 
length, is one hundred and seven millimetres after a year, 122.3 
millimetres after two years, and 136.4 millimetres after three 
years. There is an increase of forty-three per cent, in the 
course of the first year; this increase is the more rapid the 
younger the infant. After three months the foot has added 
one-seventh part to its original length, and another ninth in 
the second quarter. Therefore, recovery from a moderate de- 
gree of club-foot, when treatment begins at birth, will take 
three months; when after a year, twelve months. 

Manual correction must be resorted to many times during 
the day. At night the tender foot of the newly-born bears 
quite well a pasteboard splint, well lined, and strapped with a 
snug bandage. Later, or in procrastinated cases, a plaster-of- 



DISEASES OF THE BONES AND JOINTS. 583 

Paris bandage, or one of water-glass, or of poroplastic felt 
modelled around the foot and lower two-thirds of the leg on its 
inner side will be required to preserve the normal position. As 
there is occasional anaesthesia of the surface, great care must be 
taken lest undue pressure be exercised. After the above treat- 
ment has had a satisfactory effect, Scarpa's, Stromeyer's, 
Sayre's, or any other shoe which permits of walking should be 
used. Tenotomy is required in a great many cases, — either of 
the tendo Achillis, or the anterior tibial, or the plantar aponeu- 
rosis, or several of them at the same time. The open operation 
of A. M. Phelps (preceded by Alfred C. Post) has gained many 
friends. He cuts all the layers of the soft parts at the sole of 
the foot successively, avoiding the ramifications of the plantar 
nerve, and occasionally incising the articulations of the talus 
and of the navicular and internal cuneiform bones. Healing 
takes place under the moist blood-clot. The paralytic muscles 
require persistent use of both the interrupted and the continu- 
ous currents. The function of the muscles can be improved, 
provided the patience both of the physician and of the patient 
is equal to the necessities of the case. 

Pes equinus is the result of paralysis, either local, or spinal, 
or cerebral, and is complicated with atrophy of the muscles 
of the calf and of the sole of the foot, the sole becoming con- 
cave and the toes pointing downward. Here also tenotomy 
of the tendo Achillis and of the plantar aponeurosis, together 
with the employment of electricity and galvanism, are indi- 
cated. An apparatus is required to lift the anterior part of the 
foot, and while the patient is lying down or sitting up, soon 
after the operation he may practise upon a band properly at- 
tached to temporarily restore the normal position. Children 
will easily learn to look upon the exercise as play. 

Pes calcaneus in a mild form is often congenital and some- 
times complicated with pes valgus. The desirable position is 
restored by a shoe supplied with a high heel and so constructed 
as to press the foot down. But lately operative surgery appears 
to have accomplished some of its greatest triumphs. 



584 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Mcoladoni, to heal a talipes calcaneus with paralysis of the 
muscles of the calves, severed the peroneal muscles behind the 
malleolus and the tendo Achillis above the heel, and joined 
the central ends of the peroneal tendons to the stump of the 
tendo Achillis. Pocas, in a case of paralytic pes valgus, con- 
nected the tendons of the extensor hallucis longus and of the 
paralyzed anterior tibial. Ghillini, to supplant the action of the 
paralyzed anterior tibial muscle, cut the tendon of the peroneus 
longus near the cuboid bone, also that of the anterior tibial six 
centimetres above its insertion, and joined both by suture, with 
satisfactory result. Tendon grafting and muscle transplanta- 
tion for deformities following infantile paralysis has been prac- 
tised successfully. S. E. Milliken (N. Y. Med. Rec, November, 
28, 1896) reports on fourteen operations performed on nine 
patients. They were transplantation of the sartorius into the 
sheath of the quadriceps, the joining of the extensor hallucis 
longus to the paralyzed tibialis anticus, of the gastrocnemius 
to the peroneus longus and trevis, of the extensor digitorum 
communis to the tibialis anticus and vice versa, of the extensor 
hallucis longus to the extensor digitorum communis, of the 
flexor hallucis longus to the tibialis anticus, and of a part of 
the deltoid to the tendon of the paralyzed triceps. 

Pes valgus (flat-foot) is not infrequently congenital, the talus 
being found downward and forward. In other cases the de- 
formity is rhachitical. Both to prevent and to cure it, anti- 
rhachitical treatment and temporary rest are demanded. There 
are also (rare) paralytic cases occasioned by paralysis of the 
supinator muscles of the foot. In these electrical treatment 
and the subcutaneous use of strychnine, together with massage 
of the calf and of the sole of the foot and stimulating embroca- 
tions and friction with cold or hot water, will render service. In 
all severe cases walking should not be permitted until a reason- 
able time has elapsed; the lower extremity should be raised, 
symptoms of vascular irritation relieved by applications of cold 
water, a normal position should be enforced by plaster-of-Paris 
bandaging, which must be continued through weeks and 



DISEASES OF THE BONES AND JOINTS. 585 

months. When walking appears to be again permissible, the 
inner margin of the foot must be raised by thickening a part of 
the sole of the shoe, or by elevating it by springs which are 
elastic enough not to injure by pressure. I. Wolf insists upon 
not resting the patient at all, but makes him walk immediately 
after the application of plaster of Paris. 

From a practical point of view, the subdivision of scoliosis 
into three varieties is as follows: the first degree comprises 
those cases in which suspension of the body removes the de- 
formity altogether; the second, those in which this effect is 
but partially attained; the third, such as are not influenced 
by it. The prognosis in the first is favorable; in the second it 
is fair when the growth of the skeleton is not completed; in 
the third it is not good, but should not be considered absolutely 
bad. It greatly depends on whether the scoliosis results from 
a relative or an absolute insufficiency of muscles, or whether it 
is caused by a deformity of the vertebral bodies. The former 
may be either simply local in the muscles or depend on central 
paralysis, in poliomyelitis, in Friedreich's disease, and in some 
cases of progressive muscular atrophy. The latter may be con- 
genital, but is frequently the result of rhachitical softening 
later on. In such instances a thorough antirhachitical treat- 
ment, with proper food and hygiene and phosphorus, must not 
be postponed a single day. The habitual scoliosis of the first 
eight or ten years is of merely muscular origin, and mostly 
total and universal; the convexity generally to the left, and 
not often lumbar. This condition is found in babies who are 
persistently carried on the left arm; in school-children who 
rest the left arm on the table while the body is accommo- 
dating itself to the book and leans to the right; in girls who 
approach the bench sideways and pick up their skirts under 
the right gluteal region. The danger of becoming scoliotic is 
particularly great in those school-children whose sight is defec- 
tive. Those who stand a great deal and carry the right shoulder 
forward develop a right dorsal with a compensatory left lumbar 
scoliosis. The prevention of all varieties consists in the avoid- 



586 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

ance of their causes. A baby must not be persistently carried 
on one arm: a mother is more apt to obey this rule than a 
nurse. The muscles must be exercised at an early age, — simple 
domestic gymnastics, but not overexertion; and the habitual 
use of cool or cold washing once or twice a day, with good food 
and air and plenty of sleep on a hair mattress, are indispen- 
sable. The school lessons ought not to last more than twenty 
or forty-five minutes; there must not be too many of them; 
there should be ample light from the left side while the child 
is studying or writing; defective sight must be corrrected by 
glasses; the chairs or benches supplied with a support up to 
the lower dorsal region of the spine. During school sessions 
a light corset may also be worn, and at night an apparatus to 
restore the equality of the two sides. Massage of the defective 
side and of the muscles in general will add to the good effect, 
and the concave side of the chest may be exercised by the en- 
forcement of the habit of deep inspiration while the hand is 
firmly planted and pressed on the convexity. Dr. Teschner's 
successes are due to the systematic exercise and strengthening 
of all the muscles of the body. 

In more obstinate cases the foot corresponding with the 
lowered hip may be raised by thickening the sole of the shoe. 
Volkmann recommended the raising of the chair or bench 
under the dropping hip. Sayre's corset is either worn con- 
stantly or is made detachable. Eauchfuss's apparatus is so 
constructed as to leave the defective side but little or not at 
all supported while the patient is lying down. 

The kyphosis of feeble rhachitical children requires general 
antirhachitical treatment. The baby must not sit up until 
the muscles have become stronger; the bed should have a hair 
mattress; and the patient must take the air while being car- 
ried either on a hair mattress or in a wire cuirass, or in a tin 
or pasteboard or sole-leather mould sufficiently lined to be com- 
fortable. As the baby grows, walking must not be encouraged. 
He will rise when his bones are hard enough and his muscles 
sufficiently strong. 



XIV. 
DISEASES OF THE EAR. 

Malformations of the ear, both external and internal, are 
mostly the results of arrests of development, and are but rarely 
amenable to improvement by treatment. A faulty position of 
the auricle may be corrected after birth; when it protrudes 
unduly, bandages or adhesive plaster, worn for a number of 
weeks, will keep the organ in a more normal (adjacent) place. 
Obstruction of the auditory canal by either an epithelial or 
an organized membrane can be relieved; the former demands 
a metal probe to perforate it; the latter, a cruciform incision 
and removal of the flaps. 

Foreign hodies are common in all accessible cavities; these 
prove frequent receptacles of shoe-buttons, pearls, peas, beans, 
etc.; sometimes their removal is very difficult, particularly in 
the cases of vegetables, which swell and thereby totally obstruct 
the meatus. The use of probes during examination is some- 
times decisive in regard to diagnosis, sometimes very deceptive; 
the reflector is indispensable. The secretion of secondary 
catarrh must first be removed by syringing and wiping; pincers 
will remove a body which is not tightly incarcerated; a Daviel 
spoon, or the blunt end of a hair-pin bent upon itself, or a 
sharp spoon is often required for peas and beans. While the 
attempts at removal are going on, the ear ought to be fre- 
quently injected with warm water to expel shreds and blood 
and to facilitate inspection. Before the operation is begun, 
a cocaine solution may be instilled into the ear. A spray of 
ether may be demanded, and in urgent cases anaesthesia by 

587 



588 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

chloroform; for the extraction of a foreign body being para- 
mount, even pieces of bone have to be removed sometimes to 
render its expulsion possible. 

Living bodies, such as insects, will die in water, oil, alcohol, 
or a two-per-cent. solution of carbolic acid. Dried secretion, 
or cerumen, is softened by filling the ear with oil or glycerin and 
syringing forcibly with soap and water. The after-treatment 
may demand all the requisites of the therapy of inflammation, 
— rest, cool and disinfectant applications, erect posture, and 
narcotics. 

Otitis externa (inflammation of the external auditory canal) 
is the result of irritation by foreign bodies or by clean or dirty 
finger-nails, brushes, and sponges, also of the frequent use of 
ear-spoons, or of exposure to a high wind or draught; or it may 
depend on eczema which extends inward from the neighboring 
surface. Gronoeocci and tubercle bacilli have been met with 
in the external ear, diphtheria not infrequently, and soiled 
bathing water is probably a more common cause of ear-disease 
than is generally supposed. Now and then external otitis com- 
plicates internal, particularly in infectious diseases such as 
measles and scarlet and typhoid fevers. The general disposi- 
tion to scrofula — that means to subacute or chronic inflamma- 
tion of the tissues with rapid disintegration of the surface epi- 
thelium and insufficient tendency to reparation — is a frequent 
factor in the production of external ear-disorder, and requires 
constitutional treatment. Preventive measures are indicated 
by the causes enumerated above. Foreign bodies must be 
looked for and, if present, extracted. 

The three forms of established external otitis are the ery- 
thematous, the catarrhal, and the phlegmonous (including the 
furuncular). The first exhibits a general redness, and produces 
scales rather than secretion. An occasional application of lead 
wash, or lead ointment, or zinc ointment, or bismuth subnitrate, 
finely powdered, will be all that is required in the average cases. 
Where the redness is marked and angry, with a good deal of 



DISEASES OF THE EAB. 589 

itching, the ointment should contain five per cent, of cocaine; 
or a watery solution of cocaine hydrochlorate (two to six per 
cent.) may from time to time be brushed over the sore surface. 
The catarrhal form of external otitis is by no means a uni- 
form or always a mild affection. There may be pain, also 
secretion of a simply catarrhal or of a malodorous (fat acids) 
or cheesy nature. Erosions, ulcerations, and swelling of the 
neighboring lymph bodies are quite common. The integument 
is sometimes greatly swollen and now and then granulating; 
below and behind polypoid excrescences the bone may be af- 
fected; through the defective ossification (sometimes persist- 
ent) anteriorly and inferiorly, fistulae may form in the parotid 
region and even in the maxillary joint, and pus may find its 
way along the incisurae Santorini through the cartilaginous 
floor of the meatus. The drum membrane is frequently af- 
fected. Every form of myringitis is met with, from a slight 
hyperemia to thickening and turbidity of the membrane, even 
to perforation. Thus there is every reason for early and per- 
sistent treatment. In the interest of examination, the speculum 
must not be used at first, except in older and very docile chil- 
dren; it annoys, pains, and frightens, and is seldom as useful as 
in advanced age because of the horizontal position of the young 
drum membrane, only part of which, at best, can be seen. The 
secretion must be removed by syringing both frequently and 
forcibly (but the current must not be directed to the drum 
membrane) while the head is inclined so as to allow the instan- 
taneous egress of the fluid. The injection fluid may be warm 
water, soap and water, salt and water (6-7 : 1000), or mild 
astringent solutions of acetate of lead, sulphate of zinc, tannin, 
or alum (1 or 2 : 200); or the secretion may be removed by 
tufts of absorbent, or borated, or salicylated cotton, which are 
held tightly in a pair of pincers and not rubbed hard against 
the wall of the canal. A saturated solution of boracic acid 
(four per cent.) is both mild and disinfectant. Boracic acid 
finely powdered may be thrown in so as to fill the canal after it 



590 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

has been thoroughly dried. When the renewed secretion has 
liquefied the powder, after a few or many hours, they are both 
removed by cotton or by injections, the ear thoroughly dried, 
and boracic acid introduced again as before. Bichloride of mer- 
cury (1 : 5000) injections may be given several times a day, 
mainly when there are much hyperasmia and infiltration, in any 
of the varieties of external otitis; fomentations of the same 
solution should be made persistently. Two daily applications of 
carbolic acid in glycerin (1 : 10-20) have also been recom- 
mended; I believe they frequently irritate and fret the surface. 
Polypoid granulations have been removed by ligature. Chromic 
acid is liable to deliquesce so much, even when used carefully 
and in small quantities, as to endanger the drum membrane. 
The solid stick of nitrate of silver is safer, and requires for neu- 
tralization, after application, only a salt-water solution. A 
daily touching with liq. perchlorid. ferri or liq. subsulphat. 
ferri is very effective and quite safe. Biedert recommends the 
sozoiodolate of hydrargyrum. In external otitis leeches are sel- 
dom required, and then only when there is an excess of swell- 
ing. To relieve local pain and tension, cocaine solutions act 
better than do those of morphine. The oleate of morphia 
irritates the sore surface. Internally, a dose of morphine or 
some other opiate, or chloral, may become necessary. The pa- 
tient must be kept in a semi-recumbent or almost erect position, 
on a cool pillow, in every catarrhal or inflammatory condition 
of the ear. Cases of external otitis with copious secretion, 
complicated with or dependent on eczema, are greatly bene- 
fited by one or two daily applications of a small quantity (well 
rubbed in) of bichloride of mercury in lanolin (1 : 300-500). 
In obstinate cases of eczema a solution of nitrate of silver 
(1 : 10-50) may be brushed over the parts once every few days, 
or Lassar's paste may be used (oxide of zinc and amylum aa 25, 
salicylic acid 1, white vaseline 50), which need not be removed 
when a new application is made; or an ointment containing 
pure tannic acid and glycerin aa 4 parts, which are mixed thor- 



DISEASES OF THE EAR. 591 

oughly, and to which are added fat 30 and carbolic acid 0.3 
parts. 

The phlegmonous form of external otitis is mostly recog- 
nized with facility; the pain is intense, the swelling marked, 
more or less local, circumscribed, and red. Before an incision 
— which ought to be made in time — appears advisable, appli- 
cations of solutions of hydrargyrum bichloride (1 : 5000 water) 
are better than warm fomentations. As stated, incision must 
be made soon, and will relieve quickly. The furuncular form 
demands at once either an incision or carbolic acid treatment. 
Both should be preceded by local cocaine anaesthesia, for the 
pain may be intense. The incision must be as thorough as in a 
furuncle of any other region. It may often be substituted by 
a thorough application of concentrated carbolic acid. If ap- 
plied early, a single (or repeated) application will prove effec- 
tive. As its action is quite local, there is no danger. If the 
furuncle be pointed and the surface excessively painful, the 
acid ought to be introduced into the centre of the swelling by 
means of a slightly curved probe. 

Accompanying myringitis is apt to improve after its cause 
— the otitis externa — has been removed. A vesicatory or tinc- 
ture of iodine on and about the mastoid process is helpful. 
Direct injury of the drum membrane by cold water or salt- 
water during bathing can be averted by a wool tampon. 

Otitis media, both the catarrhal and the purulent variety, is 
a very frequent disease of infancy and childhood. Even in the 
middle ear of the newly-born accumulations are met with which 
either constitute or dispose to otitis. According to some, the 
masses frequently encountered consist of detritus developed out 
of the foetal epithelial covering; others accuse aspiration dur- 
ing and immediately after birth; some attribute the changes 
to oedema produced ex vacuo, the vacuum being due to the sud- 
den separation of the mucous membranes formerly immediately 
adjacent to each other. Infants have a large Eustachian tube, 
with a funnel-shaped pharyngeal aperture; thus infectious ma- 



592 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

terial of the common eruptive fevers, streptococci and staphy- 
lococci, the bacilli of a diphtheritic rhinitis, and even gonococci 
find an easy access. In lobular pneumonia otitis media is quite 
frequent; in scarlatina, also in measles and typhoid fever, it 
may be very severe. All the varieties of nasal, pharyngeal, and 
naso-pharyngeal catarrh, also adenoid vegetations and hyper- 
trophied tonsils, are known to be the principal causes of mid- 
dle-ear disease. Vehement spells of whooping-cough, forcible 
medicinal or other injections into the nares, and violent sneez- 
ing are apt to carry foreign material into the Eustachian tube 
and middle ear, particularly when the uvula is split in halves 
(bifida), and still more so when the hard palate is fissured; for 
in such a case the levatores palati have no support and the mus- 
cles of the tube are insufficient and atrophied. 

Preventive treatment has a wide scope. The number of cases 
of otitis media — according to Schwartze, twenty-two per cent, 
of all diseases of the organ of hearing are purulent forms of 
middle-ear disease — is as significant as its causes are manifold. 
Nasal, postnasal, and pharyngeal catarrhs must be attended to 
in their incipiency. Regular attention to the nose of infants 
would prevent much disease and many calamities. Indeed, de- 
fective hearing is more common than we suspect. Bezold found 
(1886) that of nineteen hundred and eighteen school-children, 
twenty-five per cent, had but one-third and eleven per cent, 
but one-fifth of normal hearing distance, and his statements 
have been amply confirmed. Most cases of perforation of the 
drum membrane, chronic suppuration, abscesses in the mastoid 
process, permanent paralyses of the facial nerve, and cerebral 
abscesses can be prevented by treating and curing the origin 
and fountain-head of the future distress. The hypertrophied 
mucous membrane of the nose must be reduced, adenoids re- 
moved, and enlarged tonsils resected in time. The interior of 
the nose ought to be washed — irrigated — at least once a day, 
according to known principles (p. 465). Gentle insufflation of 
the nares will clear the cavities of mucus. It may be done by 
a Politzer apparatus, or by blowing into a soft rubber tube in- 



DISEASES OF THE EAE. 593 

troduced into one nostril, while the other is kept open. There 
is better reason, from the point of view of danger to health or 
life, for washing the inside than the outside. 

A child with an acute attack of middle-ear disease ought to 
be in bed, the head raised. The symptoms are not always 
urgent or easily recognized. In the very young the large size 
of the tube facilitates the exit of the internal secretion into the 
throat, so that the drum membrane is not annoyed and pain 
from internal pressure and irritation is insignificant in many 
instances. Careful examination, however, will leave a doubt 
as to the actual seat in few cases only. A mild antipyretic, a 
small dose of a narcotic, or a purgative will ameliorate the 
symptoms. In the very beginning the Eustachian tube ought 
to be treated by inflation (Politzer) very carefully, if at all; 
older children, who can be taught the use of Valsalva's method, 
must be warned against its excessive and vehement employ- 
ment. When the acute stage has passed, both are mostly in- 
dicated. The severe pain may be relieved by a cocaine solu- 
tion (2-10 : 100) instilled into the ear, also by one or more 
leeches to the mastoid process of the affected side, in most cases 
but one side being diseased. In mild ones tincture of iodine 
alone will suffice. When the drum membrane is red, a cloth 
moistened with a solution of hydrargyrum bichloride in water 
(1 : 5000) applied to the ear and frequently repeated, will, after 
getting warm, do equally as well as the most favored warm 
poultices. When secretion of mucus or pus is increasing inside, 
the posterior half of the drum membrane is pushed out first, 
afterwards the anterior; between the two, particularly in older 
children, the hammer can be distinguished. A spontaneous per- 
foration is apt to form in the anterior portion, but the presence 
of a white discoloration does not always indicate pus. When the 
protrusion of the membrane is very marked, an incision should 
be made, mostly posteriorly and inferiorly. The general 
opinion of experts, however, is no longer in favor of indiscrimi- 
nately early operation; still, when it is performed, the incision 

38 



594 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

ought to be sufficiently large. Pus is then expelled by inflating 
through the nares (Politzer), and wiped out or carefully syr- 
inged out with a warm solution of table-salt or of boracic acid 
(3-4 : 100). The patient should rest on the diseased side. 
Boracic acid is then used as described in the rules laid down for 
its application in external otitis, or the canal is gently syringed 
with a mild solution of bichloride of hydrargyrum, or of an 
astringent, — sulphate of zinc, acetico-tartrate of aluminium 
(2 : 100-300). To what extent, during all this time, narcotics 
are to be used, or whether anaesthesia, local or general, ought to 
be employed, depends on the individual case and the judgment 
of the practitioner; also whether an antiscrofulous or antisyphi- 
litic treatment (the latter but rarely in children) be demanded. 
Chronic discharges require politzerization frequently, though 
cautiously, and the use of boracic acid and astringents; second- 
ary polypi, treatment similar to that detailed above. 

The secondary affections of the mastoid process demand 
leeches, ice, and tincture of iodine; where there is oedema, 
warm poultices and a deep incision. Abscesses of the mastoid 
process and of the brain require timely operation by an expert 
hand. The general rules laid down by Troltzsch are still valid. 
Cerebral affections due to ear-disease are, when originating in 
the external meatus and the temporal bone, in the transverse 
sinus and the cerebellum; when in the middle ear, in the cere- 
brum; when in the vestibulum and cochlea, in the medulla 
oblongata. 

In my opinion, one of the most important additions to 
modern surgery is our knowledge of the operative accessibility 
of all the spaces and nooks of the middle ear, as taught by 
Schwartze, and of the epitympanic part, by Zaufal, in all cases 
of chronic suppuration of the middle ear accompanied by sensi- 
tiveness or suppuration on the surface of the mastoid process, 
or by fistulae, with osseous stenosis of the meatus and facial 
paralysis; of middle-ear disease exhibiting cerebral symptoms, 
with or without persistent fever, though there be no external 
inflammation; also in cases of cholesteatoma of large size, with 



DISEASES OF THE EAE. 595 

alarming cerebral symptoms during the operation, particularly 
while injections are being made, or in those in which sequestra 
or foreign bodies must be removed, mainly when they give rise 
to brain symptoms; and, lastly, in cases of profuse ichorous 
secretion, or of actinomycosis, or of tuberculosis of the middle 
ear. 

Deaf-mutism is rarely a primary affection of the organ of 
hearing, though arrests of development and the results of foetal 
inflammations are not uncommon. It is also found in many 
instances of cretinism. It would be better in a large percentage 
of cases to assign it a place in connection with diseases of the 
nervous system, for most of both the congenital and the ac- 
quired cases result from cerebral affections. It is not often 
hereditary. If more extensive statistics will prove its (doubtful) 
dependency on consanguineous marriages, a wiser social hy- 
giene can be made to act as a preventive. Alcoholism of the 
parents is a cause, and society and the state, with its organiza- 
tion of ignorance and disorder, are responsible for so much of 
deaf-mutism as is not directly pathological. About half of all 
the cases are acquired, some even after children commenced to 
talk, the majority of them through cerebral and cerebro-spinal 
inflammation. According to Biedert, fifty-five per cent, are of 
that class, twenty-eight per cent, depend on acute infectious 
diseases (typhoid, scarlatina, and diphtheria, also variola and 
measles), 3.3 per cent, on traumatic injuries, and 2.5 per cent, 
on ear affections. Thus many of the congenital cases and most 
of the acquired are preventable. The treatment must be di- 
rected to so much of pathological change in the brain, the 
acoustic nerve, or the ear as is still accessible to the influence 
of either remedial or operative interference. Chronic (mostly 
interstitial) inflammations of the brain should not be given up 
as incurable as long as mercury and iodides had no sufficient 
opportunity to show its absorbent powers during a protracted 
administration. External and internal otitis, naso-pharyngeal 
catarrh, hypertrophy of the tonsils, adenoid vegetations, should 
be attended to in time, though the case appear ever so slight. 



XV. 



DISEASES OF THE EYE. 



Malformations of the eye are of different variety and gravity. 
Some cannot be corrected, such as cyclopia, microphthalmia, 
and albinismus; some need no correction, like the common 
(vertical) form of coloboma of the iris, or the congenital atresia 
of the pupil. The latter consists in the persistency of a part 
of the pupillary membrane originating from the posterior as- 
pect of the lens, and, if still extant after birth, disappears 
slowly. Others require, and are corrected by, operations. Epi- 
canthus — an abnormal accumulation of cutis near the root of 
the nose — may be removed by an operative procedure, in the 
event of its not gradually disappearing spontaneously. 

Neoplasms of the eye and eyelids are not frequent in infancy 
and childhood. Congenital ncevi of every variety, however, are 
not uncommon. Very superficial ones on the eyelids should 
be kept under observation. When uniform and rather pale, 
they are liable to heal spontaneously. When a net-work of 
enlarged blood-vessels is found on the lids or conjunctiva, there 
is often a central point the compression of which by means of a 
silver probe empties all the neighboring branches. This centre 
ought to be destroyed by a single application of the thermo- 
or galvano-cautery, or by a trace of fuming nitric acid, or by 
running a silk ligature underneath and tying it. When they 
form small or large tumors, in most cases the actual cautery 
is easier and safer than the knife. The cautery must be used 
carefully and sparingly, — rather too little than too much, ac- 
cording to rules detailed above, — and always with a view of 
avoiding a consecutive ectropium. 
596 



DISEASES OF THE EYE. 597 

Dermoid cysts are found on the lids, inside; also on the eye- 
ball; even in the orbit, from which their removal is rather dim- 
cult. They must be enucleated when the diagnosis is un- 
doubted. They have been mistakenly diagnosticated in cases 
of encephalocele of the interior angle of the eye. 

Lipoma is very rare, still more so than cysticercus celluloses. 
A few instances have been reported in which this cystic de- 
generation of the ovum of the taenia solium was found in chil- 
dren in the posterior chamber and under the skin of the lid. 

Chalazion (not always tubercular, as has been asserted) is 
a mucous cyst in the tarsal cartilage, with a tendency to indu- 
ration. The eyelid is turned over, the small tumor incised, its 
contents scraped out, and iodoform applied once. As the 
wound is covered by the lid, it heals favorably. 

Glioma of the retina (Beer's amaurotic cat-eye) develops 
rapidly. Its vascular, sometimes red and bleeding, surface dis- 
tinguishes it from suppuration of the vitreous body. It must 
be enucleated at once, as it is liable to grow rapidly in every 
direction. 

Syphilitic gummata have been observed in stray cases of re- 
tarded syphilis. They exhibit the symptoms of iritis, and 
require an ant i syphilitic treatment. 

Tubercles of the iris are, fortunately, rare. They give rise 
to an incurable chronic iritis and necessitate enucleation of the 
eyeball. Tubercles of the choroid are sometimes observed in 
the incipient, sometimes in an advanced stage of tubercular 
meningitis. They are not amenable to successful treatment. 

Foreign bodies hidden under the eyelids must be removed 
speedily, for conjunctivitis will immediately follow their pres- 
ence. They are often washed, out by the copious secretion of 
tears. The lower eyelid may be easily turned out and the cor- 
responding portion of the conjunctiva inspected. The upper 
requires turning up, which is more difficult because of the re- 
sistance of the child, but easier than in an adult, on account 
of the greater motility of the skin of the young eyelid. To 



598 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

facilitate inspection, the eye may be pressed gently backward 
into the orbit. The body, when seen, is removed by pincers, a 
fine sponge, a piece of gauze, or wiped off in the direction of the 
nose. In case of necessity, anaesthesia may be procured by a drop 
of a two-per-cent. solution of cocaine. This is indispensable 
when the foreign body is in the cornea and demands instru- 
mental removal. If it be iron, a strong magnet will remove it; 
when it is located externally, without, when in the deeper tissue, 
with, a previous operation. The danger connected with foreign 
bodies entering the eyeball, and the indication for immediate, 
or delayed, or no operation depends on the condition of the 
foreign body, which may be aseptic and not injurious, may 
irritate mechanically or chemically, or be infectious. As a 
general rule, the foreign body is readily recognized in the ante- 
rior chamber, the iris, or the lens, and should be removed im- 
mediately according to the rules laid down in ophthalmological 
works. 

Injuries of the eye by puncturing, cutting, blows, etc., re- 
quire absolute rest, the removal of foreign bodies, the applica- 
tion of ice, of atropine solution (eserine when the wound is 
peripheric), and gentle pressure. Bad cases of laceration and 
destruction are either irremediable or require special, perhaps 
operative, treatment. 

Burns should be treated on general principles. The effect of 
acids is best counteracted by copious irrigation of water, and 
cooling applications afterwards; of lime, by oil (not by water), 
and the careful removal of the foreign body, and ice applica- 
tions. 

The eyelids suffer from blepharitis mostly in scrofulous chil- 
dren, in whom dust, smoke, and infections of all kinds are apt 
to thoroughly influence the superficial tissues. It often ac- 
companies eczematous eruptions of the head and face, and is 
frequently carried by the fingers. Therefore, soap and water, 
a nail-brush, and cutting the nails short are good preventives; 
so is the successful treatment of the head and face. The bleph- 



DISEASES OF THE EYE. 599 

aritis and conjunctivitis of measles require no special local treat- 
ment; the common forms do well with a zinc ointment, or one 
of the yellow oxide of mercury with vaseline (1 : 50-100). The 
secretion must not be permitted to get dry. Hard crusts are 
dissolved by a warm solution of carbonate of sodium (1 : 100- 
200) or by frequent washing with soap and water. Grave cases 
demand epilation of the eyelashes, every one of which — so far 
as required — must be caught singly and drawn out slowly- 
enough to secure removal of the entire hair. Ointments and 
solutions of lead it is best to avoid, for complications with cor- 
neal erosions, grave or slight, are very frequent in affections 
of the eyelids and conjunctiva, and even the slightest ones may 
be indelibly stained by lead salts. 

Both the integuments and the connective tissue of the eye- 
lids being of loose structure and expansible, oedema is quite 
frequent. Insect bites are mostly diagnosticated by their cir- 
cumscribed and pointed appearance; cardiac and renal diseases 
require their own diagnoses and have their own indications; 
so has hydremia from whatever cause, besides the indications 
for the administration of iron, quinine, or arsenic. 

The conjunctiva is very liable to be affected by medicinal 
and poisonous agents. According to Silberman, aniline, potas- 
sic chlorate, and corrosive sublimate produce thrombosis; pun- 
gent gases, conjunctival hyperemia and conjunctivitis; anti- 
pyrin, urticaria of the eyelids; arsenite of copper, redness and 
corrosion; arsenide of hydrogen, a brownish-red or icteric dis- 
coloration; bromide of potassium, simple or phlyctenular con- 
junctivitis, without, however, influencing the blood-vessels of 
the interior; chrysarobin, a local inflammation; coniin, a burn- 
ing sensation; ergotin, hemorrhages; iodide of potassium, in- 
flammation; iodoform, when applied locally, an erysipelatous 
tumefaction; and salicylate of sodium, oedema and a bluish ex- 
anthem; in larger doses, tumefaction and vesicular eruption. 
Still, cases of conjunctival disease depending on these agents 
are comparatively rare. 



600 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

The majority of the diseases of the conjunctiva are of an 
inflammatory character. In a number of cases of conjunctivitis 
the conjunctiva of the bulbus does not participate extensively. 
Common forms of fevers, also whooping-cough and principally 
measles, are among the causes of acute conjunctivitis. Some- 
times there is but little redness; the lids are thickened and 
stiff with oedema. In other cases there is plenty of mucus, 
sometimes purulent, now and then with a tendency to coagu- 
lation, but not to such a degree as to render difficult the dif- 
ferential diagnosis from diphtheria of the eyelids. The mucous 
secretion must be wiped off with absorbent cotton or a moist 
cloth, boracic acid solution of three per cent, should be applied 
or instilled, and cold water employed at intervals of from one 
to ten minutes; chlorine-water, if obtainable fresh (a teaspoon- 
ful in a glass of water), should be used for applications; if the 
surface secretes much, corrosive sublimate (1 : 4000-5000). If 
the secretion be purulent, nitrate of silver, 1 part in 100 or 
500 parts of distilled water (black bottle), must be applied once 
a day, best with a brush, and washed off with pure water. A 
high degree of congestion, with phlyctenular eruptions,— 
sometimes unilateral only, not infrequently combined with 
blepharitis, — demands persistent application of cold, best by 
keeping a number of small pieces of cloth on a lump of ice and 
applying them at short intervals until they begin to get warm. 
Atropise sulphas (1 : 200-500) should be instilled once or twice 
a day, and the lids kept at rest. To hold them immovable, if 
the patient be very young, a layer of absorbent cotton should 
be covered with, or slightly soaked in, collodion and applied 
after the eye has been wiped dry. Later an ointment of the 
yellow precipitate of mercury (1 : 50-100), or calomel finely 
powdered, may be employed once a day. 

Chronic conjunctivitis presents in many cases few symptoms 
only. The superficial hyperaemia does not always correspond 
with the burning sensation often complained of, and the mu- 
cous secretion is but trifling, and collects mostly in the inner 



DISEASES OF THE EYE. 601 

angle of the eye. Overexertion of school-children, particularly 
of those who are hypermetropic or astigmatic, diseases of the 
nose of a catarrhal or ulcerous nature, indigestion and constipa- 
tion, anaemia, scrofulosis, or trichiasis are just so many causes 
and require the appropriate causal treatment, both medicinal 
and hygienic, change of air (country), and cool and cold bath- 
ing. These measures often suffice to relieve even secondary dis- 
orders of the lymph circulation, which is easily disturbed. Like 
the orbits which discharge their lymph-ducts into the deep facial 
lymph-bodies, the lids and conjunctivas are connected with the 
glands of the aural and submaxillary regions. The medicinal 
treatment is disinfectant and astringent; the remedies must be 
changed from time to time. Sulphate of zinc (1 : 250-500) 
with or without cocaine muriate (1-2 : 100), in more protracted 
cases ointments of sulphate of zinc or sulphate of copper 
(1 : 100-150), solutions of boracic acid (3 : 100) or of sodium 
carbonate (1 : 100-200), in suppurating cases a daily brushing 
with nitrate of silver (1 : 250-1000), combined with scrupulous 
cleanliness and avoidance of vascular stimulants, will meet all 
indications. 

The chemosis of scleral conjunctivitis does not require any 
additional applications; mild astringents and rest will suffice. 
Subbing, constipation, and coughing result in hemorrhagic dis- 
coloration (general blueness or extravasations) which requires 
rest and cool (or warm) fomentations. 

Diphtheritic conjunctivitis cannot readily be mistaken. The 
infiltration is hard and the pseudo-membrane not removable. 
There is no secretion; indeed, the eye is dry to such an extent 
that the pressure of the exudation alone ulcerates the cornea. 
Absolute caution in every case of — particularly nasal — diph- 
theria, and covering the healthy eye, when (as usual at first) 
but one eye is affected, with a cotton and collodion application, 
aided by more cotton and a bandage, are indispensable. Thor- 
ough and speedy mercurialization and antitoxin are indicated. 
Papayotin (1 : 5-10 of water and glycerin), not to be sub- 



602 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

stituted by "papoid," may be applied every hour. Nitrate of 
silver deserves no recommendation. Chlorine-water, carefully 
applied while the eyelid is kept away from the eyeball, when- 
ever that is possible, may render good service. Ice must be 
applied carefully and persistently. 

Most cases of gonorrhceal conjunctivitis are contracted during 
birth from the gonococcal discharge of the maternal vagina; 
others through handkerchiefs, towels, fingers, or bathing water. 
Its treatment has been discussed (p. 117). 

Trachoma, possibly of a microbic, surely of a specific char- 
acter, consists of granular deposits and proliferation of cells 
which crowd upon the normal tissue and render it atrophic. 
Its duration is long; its treatment must be persistent. The 
acute attack, or stage, requires daily brushing with nitrate 
of silver (1 : 100), and washing off with water when the first 
effect of the caustic becomes visible. The subacute cases de- 
mand a daily (or less frequent) application of the sulphate of 
copper stick. The granulations may also be scarified, scraped 
out, or squeezed out, — an old operation successfully re-estab- 
lished by modern surgery. Many cases do well with a daily 
application of one part of bichloride of mercury in one thou- 
sand parts of distilled water. The conjunctival duplicature, 
which is the pet seat of trachoma, has been excised to get rid 
of a large part of the diseased masses at once. For domestic 
treatment, an ointment of sulphate of copper and vaseline (1 : 
100), with or without cocaine muriate, will prove beneficial. 
A similar treatment, somewhat modified and diluted, is ap- 
plicable to what is described as granular conjunctivitis, which 
probably is in no case anything but a mild form of trachoma. 
Follicular conjunctivitis is probably of the same nature in many 
cases; usually it is described as an inflammation of the (micro- 
scopically small) glands of the conjunctiva. The follicles are 
in rows near the margin of the eyelids. It is complicated with, 
or depends on, the presence of foreign bodies, of nasal disease, 
or of other varieties of conjunctivitis, and is not infrequently 



DISEASES OF THE EYE. 603 

found in large numbers in families and in schools. The treat- 
ment is milder than that of the previous forms, — rest, washing, 
boracic acid solutions, astringents. 

Keratitis, beginning with a small vesicle, which is mostly not 
observed, and rapidly terminating in a superficial ulceration, is 
frequently met with in "scrofulous" children, who, besides, suf- 
fer from affections of the mucous membranes of the nose, lips, 
and ear, from eczema, glandular tumefactions, etc. Some pa- 
tients are rickety. To overcome the spasm of the conjunctiva, 
cocaine is often required to facilitate examination; for that 
purpose the dipping of the head into cold water, a popular 
remedy for photophobia, is probably not convenient. The con- 
stitutional disorder must be combated by cleanliness, fresh 
(country) air, bathing, plain and nutritious diet, quinine in 
small, iodide of iron in proper doses. Iodide of potassium in 
small doses (grs. 1-2), three times a day, given for a long time, 
is very successful in many cases. The room must be kept 
moderately dark and the eye protected by a shield. Good local 
applications are chlorine-water diluted in from twenty to one 
hundred parts of water, corrosive sublimate (1 : 5000), boracic 
acid (3 : 100), atropine solution of one-half per cent., or cocaine 
solution of two per cent, (the last two occasionally in combina- 
tion). When the ulceration is near the corneal margin, eserine 
is recommended in place of atropine; but it is advisable to re- 
member that it produces a congestion of the iris and may pre- 
dispose the latter to be drawn into the morbid process. Old 
cases will do well with occasional (one every day or two days) 
gentle applications of nitrate of silver (1 : 200-500) or (particu- 
larly when the conjunctiva is pale) of finely powdered calomel; 
this latter has always been highly recommended, and is useful, 
if persistently used through weeks and months, when turbidity 
of the cornea remains behind. Old cases with defective power 
of reparation will do well when the lids and eyeball are gently 
kneaded with an ointment of the yellow precipitate of mercury 
(1 : 50). In many instances some of these remedies will act 



604 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

better than others; alternation is often required. A simple 
ulceration, no matter what application is employed, will heal 
better, or best, by avoiding friction of the eyelids; they ought 
to be immobilized by cautious bandaging, which may be re- 
moved to make the demanded local applications. Under the 
bandage a cloth wet with a solution of corrosive sublimate (1 : 
5000) or boracic acid (3 : 100) will prove quite acceptable and 
beneficial. Suppurating ulcerations lead to hypopyon and per- 
foration. They require, besides atropine, or eserine when near 
the margin, occasional applications of corrosive sublimate (1 : 
2000) or nitrate of silver (1 : 100). Biedert recommends co- 
caine and scraping or burning of the abscess. According to 
him, the main obstacles in the way of speedy recovery are: com- 
plications with conjunctivitis, blepharitis, nasal affections, 
stenosis of the lachrymal duct and blennorrhea of the lach- 
rymal sac (but rarely its congenital obstruction), and blepharo- 
phimosis with photophobia and rhagades. 

Parenchymatous or diffuse keratitis is a peculiar variety. 
The turbidity and thickening of the two cornese (the process 
being bilateral) are extensive, not always uniform, often dis- 
seminated, and complicated with considerable vascular injec- 
tion on and around the corneae and with synechia of the iris. 
Very many cases of this variety — according to some, the vast 
majority, ninety-six per cent., according to Parinaud, thirty 
per cent., according to Siklossy — are the results of syphilis, 
either hereditary, or acquired, or retarded hereditary. They 
require persistent antisyphilitic treatment with iodide of po- 
tassium (and mercury). Scrofula, rhachitis, malaria, and ar- 
thritis are also charged with producing this form. It is 
certainly true that iodine and mercurial treatment are not 
always successful. Some cases are benefited by salicylate of 
sodium. Atropine is useful in all. 

In neuroparalytic keratitis both the conjunctiva and the 
cornea are deprived of sensibility, the lids do not move, the 
eye is kept open, the cornea is dry (xerosis) and may undergo 



DISEASES OF THE EYE. 605 

softening (keratomalacia), with the result of either perforation 
or incurable turbidity and local thickening. It is met with 
in severe infectious fevers, particularly during the unconscious 
state of typhoid, and in the coma of encephalitis. These 
results are not often met with for a long time in succession, 
for most of the patients die of the original disease. They have 
also been noticed during and after frontal and conjunctival 
herpes zoster. In all these cases the eyeball must be moistened 
with salt and water (6-7 : 1000) and the lids closed by a band- 
age or by cotton with collodion. In most cases the latter will 
prove as effective as suturing of the two eyelids. Xerosis of 
the conjunctiva is also noticed, in very young infants, as the 
result of ill nutrition and consecutive marasmus. Most of the 
patients are from two to six months old. Proper and sufficient 
food will sometimes restore both the eye and the general health, 
but the mortality of these cases is very high. The same con- 
dition is found in children of from three to nine years (Thal- 
berg, Forster). Several such cases were complicated with 
hemeralopia. 

Keratoconus — the conical raising of the centre of the cornea 
— requires a cautious thermo- or galvano-cauterization; pan- 
nus, the centre of which is generally absolutely deprived of 
blood-vessels, demands stimulation. Daily insufflation of finely 
powdered calomel, continued for weeks or months, has met 
with some successes. Infection with erysipelas and gonorrhoea 
has been observed to restore circulation and absorption, and the 
latter has been utilized, consequently, to accomplish these ends. 

Acute iritis is rare in infancy and childhood; its complica- 
tion with glaucoma still more so. Of its two great causes, 
syphilis is almost exclusively of the hereditary variety, and 
rheumatism exhausts its main danger in starting endocarditis. 

Chronic iritis is not so often seen in early life, except in con- 
nection with diffuse keratitis. The treatment of iritis is essen- 
tially identical with that of the same affection in adults: 
hydrargyrum, iodides, and salicylates, according to the causal 



606 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

indication; instillations of atropise sulphas in distilled water 
(1 : 100-500) from two to ten times a day, or oftener if the 
danger of adhesion be imminent, with a two-per-cent. solution 
of muriate of cocaine if the pain be great; absolute rest in 
the acute variety; dry heat; a dark room; iridotomy, or rather 
iridectomy, in most cases to loosen synechias and restore a pupil. 
Subconjunctival injections of corrosive sublimate (1 : 1000, a 
few drops at a time) were used by Darier in 1892, and in 
Deutschmann's clinic. They are made near the margin of the 
cornea and downward, and are recommended principally for 
syphilitic affections of any part of the eye, except, perhaps, 
the optic nerve. Parenchymatous keratitis and iritis are also 
said to be amenable to the same treatment, though they be not 
syphilitic. Later reports are not quite so favorable. 

Suppurative cyclitis and a true abscess of the vitreous body 
are generally found together. Blindness is imminent, and enu- 
cleation to save the other eye becomes a necessity in almost 
every case, except in small children. In them the process has 
often exhausted itself, and may terminate in blindness and con- 
traction without secondary irritation. When the abscess is 
small, part of it may be absorbed, and a white cloud in the 
lower part of the vitreous body, and feeble vision, may be the 
only evident results. 

Uncomplicated inflammation of the choroid is rare in chil- 
dren. Idiopathic choroido-retinitis is observed in later years 
in both eyes after it has lasted a long time. It certainly com- 
mences at an early age, but takes decades before it ends in con- 
traction of the field of vision, degeneration of the retina and 
optic nerve, and turbidity of the vitreous body and the pos- 
terior capsule of the lens. In all cases, whether syphilitic or 
not, treatment with mercury and iodides is the only one either 
reliable or advisable. 

Congenital cataract demands an operation if vision be in- 
sufficient. If it be partial, atropine and iridectomy will suffice. 
Total cataract is rare in early years; more frequent is zonu- 



DISEASES OF THE EYK 607 

lar cataract, which exhibits round its nucleus one or more 
turbid layers, followed by normal clear ones. As at the same 
time in a number of cases transverse phosphatic deposits are 
found in the teeth, zonular cataract has been attributed by 
many to rhachitis; others connect it with convulsive diseases. 
Some constitutional disorder has been charged with being the 
cause, but no treatment has been advised, nor is there any 
apparent indication, except to correct the accompanying 
myopia. 

Disease of the retina, the optic nerve, and the orbit show no 
particular symptoms in the young, nor do they require special 
treatment different from that employed in advanced age. In 
many cases of acute or chronic leptomeningitis with ample 
effusion, blindness depending on copious secretion in and 
around the tissue of the optic nerve is an early s}'mptom. 
Early diagnosis of this condition, and treatment with mercury, 
iodides, and derivants (diuretics, purgatives, diaphoretics), 
may succeed in reducing the cedema and preventing compres- 
sion and atrophy of the nerve. A number of such cases will 
get well. 

The tissues of the young eye being soft and elastic and ex- 
pansible from internal pressure, glaucoma is but rarely seen at 
an early age. Its place is taken by hydro phthalmos (buph- 
tlialmos), which requires the operative procedures employed for 
the glaucoma of advanced age, — either iridectomy or scle- 
rotomy. 

Strabismus is common in infants during the first few months 
of life. In them it is the result of an insufficient development of 
muscular power in general and of accommodation, and re- 
quires no treatment. That which makes its appearance during 
convalescence or in general hydremia terminates in recovery. 
Diphtheritic paralysis of the muscles of accommodation re- 
covers spontaneously, or through generous feeding and the 
administration of iron and strychnine. Muscular paralyses re- 
sulting from cerebral diseases depend on these for their treat- 



THERAPEUTICS OF INFANCY AND CHILDHOOD. 

ment, if any be possible. The ordinary form of ophthalmo- 
plegia, for instance, depends on nuclear degeneration. Still, 
there are a number of hereditary cases reported by Gourzein 
and considered by him as solely muscular. In them the ptosis 
was very marked; there was also nystagmus, and some am- 
blyopia. Persistent strabismus in children of five or six years 
requires the same methods of operative treatment as that of 
adults. 



NAMES. 



Abbe, 405. 

Abercrombie, 549. 

Ahlfeld, 96. 

Alexandroff, 371. 

Almquist, 547. 

American Pediatric Society, 284. 

Auerbaeh, 31. 

Baginsky, 277, 280, 283, 549. 

Bani, 90. 

Barth, 549. 

Baruch, 63, 489. 

Bassini, 413. 

Battersby, 327. 

Baumann, 158. 

Baumgarten, 252. 

Beely, 326. 

Behring, 77, 277. 

Benedict, 345. 

Beneke, 289, 527. 

Benney, 284. 

Bezold, 592. 

Biedert, 30, 34, 40, 175, 321, 590. 

Bienwald, 113. 

Bier, 576. 

Biermer, 404. 

Bieser, 468. 

Binz, 44, 304. 

Blumenthal, 241. 

Boas, 12, 59. 

Bonn, 448. 

Bokay, 424. 

Bouchut, 168, 534. 

Bourneville, 317. 

Brackett, 560. 



Braman, 549. 
Brenz, 119. 
Bretonneau, 40. 
Broca, 404. 
Brothers, 90. 
Broussais, 9. 
Brown, 284, 476. 
Bruns, 575. 
Budin, 110. 
Bull, 195. 
Biinger, 576. 

Caille, 32, 66, 81, 302, 323, 479. 

Calot, 570. 

Campbell, 432. 

Cantani, 167, 218. 

Caron, 166. 

Cattani, 116. 

Chapin, 96. 

Chossat, 9. 

Coates, 121. 

Coit, 35. 

Cohn, 24, 25. 

Coley, 78, 356, 424. 

Concetti, 363. 

Conquest, 326. 

Craig, 101. 

Crede, 96, 106. 

Cruveilhier, 529. 

Cunningham, 161. 

Curling, 415. 

Dana, 353. 

D'Arcy Power, 120. 121, 461. 
Darier, 606. 
39 609 



610 



NAMES. 



Delstauche, 370- 
Demme, 448. 
Demuth, 304. 
Deutschmann, 606. 
Dew, 90. 
Dieulafoy, 369. 
D'Outrepont, 96. 
Dowd, 414. 
Doyen, 160. 
Ducrey, 250. 
Dujardin-Beaumetz, 59. 

Ebstein, 23. 

Edes, 161. 

Edlefsen, 285. 

Einhorn, 382. 

Elsaesser, 141. 

Englisch, 448. 

Epstein, 104, 549. 

Escherieh, 25, 116, 283, 395. 

Esmarch, 417, 576. 

Evans, 308. 

Ewald, 12, 382. 

Ewing, 278. 

Falkland, 42. 
Fede, 363. 
Ferreire, 250. 
Finkelstein, 382. 
Finotti, 578. 
Fischer, 309, 371. 
Flechsig, 353. 
Fleisch, 347. 
Fliigge, 26, 174. 
Forchheimer, 304. 
Forster, 605. 
Foster, 53. 
Fournier, 421. 
Fowler, 413. 
Fraenkel, 158, 365. 
Freeman, 32. 
Freudenreich, 178. 



Friedleben, 160. 
Fiirbringer, 323, 324. 

Gaertner, 39, 136. 
Gerster, 317, 350, 371. 
Ghillini, 584. 
Gibier, 354. 
Gilbert, 421. 
Gillette, 560. 
Glas, 347. 
Gleitsmann, 367. 
Gottstein, 370. 
Gourzein, 608. 
Gowers, 159, 338, 353. 
Gerhardt, 348, 349. 
Graves, 9. 
Greatgood, 326. 
Grenser, 89. 
Greves, 422. 
Griesinger, 412. 
Guaita, 304. 
Guerin, 447. 
Guersant, 453. 
Guillot, 103. 
Guyon, 448. 

Haase, 326. 

Haftkin, 77, 218. 

Hamill, 431. 

Hammarsten, 27. 

Hawkins, 404. 

Health Department of New York, 

230. 
Hebra, 548. 
Heffen, 523. 
Heiman, 330. 
Hessing, 564. 
Heubner, 29, 35, 137, 143, 166, 195, 

277, 280, 283. 
Hirscb, 347. 
Hirschfeld, 44. 
Hjort, 371. 



NAMES. 



611 



Honing, 326. 
Hoffa, 564, 565, 566. 
Hoffmann, 376. 
Hofmeier, 107. 
Holt, 33, 169, 197. 
Honigmann, 24. 
Hopkins, 472. 
Horsley, 158. 
Howard, 90. 
Huber, 241. 
Hueter, 250. 
Huguenin, 326. 
Hun, 162, 317, 318. 

llling, 107. 

Jacoby, 323, 324. 
Jastrowitz, 353. 
Jenkins, 97. 
Johnston, 303. 
Jolly, 353. 

Kamienski, 534. 

Kaposi, 542. 

Kassowitz, 141. 

Kauffmann, 448. 

Kiliani, 324. 

Kinnicutt, 162. 

Kitasato 341. 

Klebs, 183, 184. 

Klemperer, 43. 

Knaggs, 408. 

Knapp, 196, 350. 

Knochenstein, 24. 

Kobert, 130. 

Koch, 164, 173, 175, 183. 

Kocher, 119, 413, 453, 568. 

Koenig, 160. 

Koster, 572. 

Koplik, 28, 155, 216, 277, 367, 571. 

Kopp, 96. 

Korowin, 30. 



Kraske, 251. 
Kriiger, 11. 
Kulz, 166. 
Kummell, 159, 566. 
Kiister, 575. 
Kussmaul, 58, 408. 

Laborde, 92. 

Landau, 114. 

Landerer, 577. 

Landolt, 560. 

Langenbeck, 564. 

Lannelonguc, 316, 413, 577. 

Lanz, 143. 

Lassar, 101, 550. 

Lauth, 92. 

Lepine, 130. 

Leroux, 166. 

Letzerich, 304. 

Lexer, 254. 

Liebig, 44. 

Liebreich, 183. 

Loe wen m ever, 436. 

Lorey, 303. 

Luschka, 529. 

Macalister, 161. 
McEwen, 581. 
Mackenzie, 161. 
Malay, 11. 
Marie, 161, 354. 
Maragliano, 183. 
Marmorek, 78, 252. 
Marshall Hall, 90. 
Meckel, 108. 
Meigs, 34, 35, 308. 
Meltzer, 313. 
Menard, 103. 
Meyer, 251, 369, 577, 582. 
Michael, 303. 
Mikulicz, 161, 560. 
Milliken, 584. 



612 



NAMES. 



Mills, 350. 
Miquel, 178. 
Mitchell, 176, 572. 
Mitchell, J. K., 312. 
Moncorvo, 303, 304, 372, 539. 
Mouflier, 349. 
Moore, 96. 
Morton, 314, 340. 

Neisser, 553. 

Nelaton, 413. 

Nelson, 508. 

Netter, 309. 

Neuhaus, 554. 

Neumann. 24, 25, 107, 548. 

Nicoladoni, 584. 

Nicolaier, 341. 

Nichols, 571. 

Northrup, 33, 169. 

Oertel, 436, 514. 
Oliver, 70. 
Ombreville, 413. 
Oppenheimer, 159. 
Osier, 162. 
Owen, 161. 

Paci, 564. 
Pacini, 90. 
Palleske, 24. 
Parrot, 567. 
Pasteur, 354. 
Pavy, 17. 
Peck, 254. 
Pepper, 308. 
Pfeitfer, 215. 
Pernice, 92. 
Phelps, 579, 583. 
Philippson, 549. 
Pitts, 409. 
Pletzer, 423. 
Pocas, 584. 



Porak, 107. 
Post, 583. 
Putnam, 350. 

Quincke 323. 

Kabinowitsch , 175. 

Radclifle, 353. 

Ranke, 236. 

Rauchfuss, 586. 

Rauschenbusch, 278. 

Raymond, 549. 

Redman, 96. 

Redon, 166. 

Rehn, 305, 326. 

Reich, 89. 

Reinbach 159. 

Reiner, 451. 

Ribemont, 90. 

Riedel, 251. 

Riehl, 547. 

Rieth, 43 

Ritter, 548. 

Rosenberg, 478. 

Rosenheim, 12. 

Rotch, 32, 36, 66, 96, 136. 

Roux, 77, 277, 280, 283. 

Rudisch, 42, 47, 382, 385, 511. 

Rummo, 130. 

Sachs, 317, 330, 350. 
St. Germain, 414. 
Salkowski, 28. 
Sands, 409. 
Sayre, 138, 570. 
Scanzoni, 103. 
Schaefer, 70. 
Schallern, 118. 
Schede, 566. 
Schifier, 30. 
Schild, 24. 
Schleich, 78. 
Schleif, 161. 



NAMES. 



613 



Schliep, 302. 
Schmidt, 367. 
Schott, 515. 
Schuchardt, 175. 
Schiiller, 90. 
Schultze, 90. 
Sehwartze, 592, 594. 
See, 530. 

Seibert, 32, 215, 216. 
Shaffer, 559. 
Siegfried, 28. 
Silbermann, 599. 
Silvester, 90. 
Sinclair Tousey, 554. 
Smellie, 89. 
Smith, A. H., 58. 
Solera, 11. 
Solis-Cohen, 161. 
Sonnenberger, 304. 
Soxhlet, 26, 34, 6(j. 
Springer, 38. 
Starr, 317, 318. 
Stepp, 309. 
Strelitz, 547. 
Sydenham, 9. 

Tarnier, 96. 
Taylor, 579. 
Teschner, 586. 
Thalberg, 605. 
Thallon, 274. 
Thin, 548. 
Tizzoni, 116. 
Tordeus, 548. 



Trendelenburg, 554. 
Treves, 412. 
Tubby, 566. 

Uffelmann, 12. 

Van der Veer, 317. 
Vargas, 571. 
Villate, 576. 
Virchow, 118, 163, 530. 
Volkmann, 564. 
Vogel, 144, 308. 
Voit, 44. 

Waldeyer, 118. 

Weber, 549. 

Wegeli, 166. 

Wegner, 141, 194. 

Weiss, 473. 

Wendt, 304. 

West, 215, 216, 326. 

Widerhofer, 193, 280. 

Widowitz, 309, 548. 

Wieland, 574. 

Willard Parker Hospital, 255. 

Williams, 215, 216. 

Winckel, 96, 111. 

Wittmaack, 28. 

Wladimiroff, 548. 

Woihler, 90. 

Wolf, 566. 

Wroblewski, 28. 

Zaufal, 594. 
Zweifel, 11, 30, 106. 



INDEX. 



Abscess of the vitreous body, 606. 

Abstinence in enteritis, 50. 

Acid, hydrochloric, 12; organic, 12. 

Acne, 540. 

Acute articular rheumatism, 288 ; 
blood in, 289. 

Addison's disease, 71, 161, 162. 

Adenitis in hereditary syphilis, 196 ; 
in diphtheria, 271 ; sublingual, 
361. 

Adenoid vegetations, 369 ; in diph- 
theria, 258. 

Adenoma, 118; of the liver, 402. 

Adhesion of the prepuce, 449. 

Administration of medicines, 66. 

Adrenals, 70, 161. 

Akromegaly, 161, 162. 

Albinismus, 596. 

Albumose, 41 ; in rectal alimenta- 
tion, 58. 

Alcohol, 44 ; in sepsis, 44 ; in diph- 
theria, 263 ; in typhoid fever, 210. 

Alexin, 77. 

Alimentation, rectal, 57. 

Alkalies, 46, 48, 49 ; in gastric ulcer- 
ation, 384. 

Ammonium chloride, 79 ; no stimu- 
lant, 210. 

Amygdalitis, 365 ; follicular, 366. 

Amyl nitrite, 80. 

Amyotrophic sclerosis, 334. 

Anaemia, 122; primary, 122; causes 
of, 122 ; chronic, 123 ; food in, 



125 ; hygiene in, 126 ; from gastric 

catarrh, 127; digitalis in, 127; 

strychnine in, 128 ; iron in, 128 ; 

cerebral, 320 ; splenic, 134. 
Anaesthesia, by infiltration, 78 ; not 

in mouth operations, 82. 
Anchylostoma duodenale, 411. 
Aneurism, 530. 
Angioma, 532. 
Ankle-joint, 581. 
Ankyloglosson, 364. 
Antipyrin as a styptic, 122. 
Antitoxin, 476 ; of diphtheria, 277 ; 

eruptions after, 278. 
Anus, prolapse of, 414 ; fissure of, 

417. 
Aphthae, Bednar's, 359. 
Aphthous vulvitis, 454. 
Appendicitis, 403 ; operation in, 404. 
Applications, dry, to skin, 86. 
Arrest of development in nervous 

system, 318. 
Arsenic, 130 ; in various anaemias, 

131 ; in intermittent fever, 198 ; in 

tuberculosis, 179. 
Arteritis, umbilical, 109 ; diagnosis 

of, from phlebitis, 110. 
Arthritis deformans, 571. 
Articular rheumatism, acute, 288 ; 

chronic, 297. 
Ascaris, 509. 
Ascites, 402. 
Asiatic cholera, 217. 

615 



616 



INDEX. 



Asphyxia, 88; causes of, 88; pre- 
ventive treatment of, 88 ; treat- 
ment of, 90 ; electricity in, 92. 

Aspiration of meconium, 89. 

Asthma, 482 ; dyspeptic, 482. 

Asymmetry of cranium, 140. 

Atelectasis, 482 ; causes of, 95 ; treat- 
ment of, 95. 

Atheroma, 554. 

Athetosis, 348. 

Atresia of the pupil, 596 ; of the 
vagina, 458. 

Atrophy, acute yellow, 422 ; mus- 
cular, 315 ; of the skin, congeni- 
tal, 555. 

Autoinfection, 538. 

Bacilli, dissemination of, 170 ; in- 
halation of, 173. 

Bacteria in diarrhoea, 495. 

Balanitis, 456. 

Balano-posthitis, 456. 

Barley, 22. 

Barlow's disease, 165. 

Bath, cold, 65 ; warm, 65 ; hot, 65 ; 
the first, 100. 

Bathing, 63, 100. 

Bednar's aphthae, 359. 

Beef-broth, 41. 

Beef-scraped, 42. 

Beef-tea, 40, 41. 

Biliary ducts, congenital obliteration 
of the, 114. 

Bladder, 441 ; local treatment of, 
443 ; spasm of, 442 ; irritable, 
443 ; diphtheria of, 444 ; muscular 
debility of, 444, 446. 

Bleeding, cause of, 163. 

Blennorrhoea, 117 ; nitrate of silver 
in, 117. 

Blepharitis, 598. 

Blood, diseases of the, 122 ; in acute 



articular rheumatism, 289 ; of the 
infant, 125. 

Blood-pressure, 517; reduced, 517. 

Blood-vessels, 530 ; hypoplasia of, 
530 ; thinness of, 530. 

Boiling milk, effects of, 23. 

Bones, 562 ; congenital malforma- 
tions of the, 462 ; curvatures, 562 ; 
rhachitical curvatures, 562 ; frac- 
tures, 566. 

Brachial plexus, paralysis of, 314. 

Brain, tumors, 317 ; symptoms in 
typhoid fever, 209. 

Bromides, 342. 

Bromoform, 309. 

Bronchi, 479. 

Bronchial catarrh, 479 ; chronic, 481. 

Bronchitis, 479 ; complication with 
asthma, 480; fibrinous, 481 ; in 
typhoid fever, 203. 

Bulbar paralysis, 328. 

Buphthalmos, 607. 

Burns, 535. 

Butter, 175. 

Calcium, 53. 

Calculi, renal, 439. 

Calomel in hereditary syphilis, 193. 

Cane-sugar, 16, 31. 

Cantharidal collodium, 85. 

Cantharidin, 183. 

Caput obstipum, 559. 

Carbolic acid, 234. 

Casein of different milks, 21. 

Caseous pneumonia, 170. 

Catalepsy, 346. 

Cataract, congenital, 606. 

Catarrh, acute gastric, 47 ; chronic 
gastric, 48 ; acute nasal, 463 ; 
chronic, 465, 470 ; chronic laryn- 
geal, 472; bronchial, 479 ; vulvar, 
456 ; vaginal, 456. 



IXDEX. 



6i; 



Catarrhal fever, 217. 

Caustics in naevus, 532. 

Cautery in naevus, 532. 

Cereals, 29 ; admixture to milk, 29, 

30. 
Cerebral diseases, feeding in, 5G 

meningitis, 318; hyperemia, 319 

anaemia, 320 , thrombosis, 320 

embolism, 320. 
Chalazion, 597. 
Cheese, 175. 
Chemosis, 601. 
Chest, deformities of, 497. 
Chicken-pox, 247. 
Child, peculiarities of the, 10. 
Chlorate of potassium, 259. 
Chloride of iron in diphtheria, 272 ; 

in membranous croup, 273. 
Chloroform, 80, 81; in obesity, 82; 

in pneumonia, 82 ; in heart-dis- 
eases, 82. 
Chlorosis, 132 ; anatomical cause of, 

132; haemoglobin in, 132; blood 

in, 132. 
Cholera, Asiatic, 217. 
Chorea magna, 347 ; minor, 343 ; in 

rheumatism, 292. 
Choroid, 606. 

Chronic articular rheumatism, 297. 
Chyluria, 534. 
Circular dementia, 329. 
Circulation, organs of, 511. 
Cirrhosis, congenital, 114. 
Climate in tuberculosis, 176. 
Clothing in tuberculosis, 178. 
Club-foot, 582 ; after poliomyelitis. 

339. 
Coal-tar preparations, 64. 
Cocaine injections, 78. 
Cod-liver oil, 53 ; action of, 137. 
Cold water in typhoid fever, 204. 
Colic. 392. 



' Collodium, cantharidal, 85. 

j Coloboma, 596. 

i Colon descendens, 121. 

Compensation in heart-disease, 522. 

Compressed air in pertussis, 302. 

Concretions in mouth, 357. 

Congenital constipation, 121 ; luxa- 
tions, 564; myotony, 315. 

Conjunctiva, 599 ; inflammation 
of, 599 ; scleral, 001 ; diphtheria 
of, 601 ; gonorrhoea of, 602 ; tra- 
choma of, 602 ; granulations of, 
602 ; follicles of, 602. 

Constipation by starchy food, 52 ; 
lack of sugar, 52 ; causes of, 51 ; 
apparent, 51 ; by casein, 52 ; con- 
genital, 121 ; in rhachitis, 146 
in typhoid fever, 297 ; actual, 387 
apparent, 387 ; congenital, 388 
medication in, 390, massage in, 
391 ; electricity in, 391. 

Constitution, diseases of the, 122. 

Convalescence, 126. 

Convulsions. See Eclampsia. 

Cord, treatment of the, 106 ; liga- 
ture of the, 106 ; dry treatment of 
the, 108. 

Corrosive sublimate, 235. 

Cough, periodic night, 483. 

Couveuse. 96. 

Cow's milk not woman's milk, 29. 

Coxitis, 579. 

Craniotabes, 140. 

Craniotomy, 316. 

Creosote in tuberculosis, 182. 

Cretinism, 330; treatment of, 157. 

Croup, pseudo-membranous, 473 ; 
pseudo, 472 ; mercury in, 475 ; in- 
tubation in, 475; antitoxin in, 476. 

Cryptorchis, 459. 

Cyclitis, 606. 

Cyclopia, 577. 



618 



INDEX. 



Cystic lymphangioma, 534. 
Cystitis, 441. 

Deaf-mutism, 595. 

Degeneration, acute fatty, 111. 

Delirium tremens, 329. 

Dementia, 329 ; epileptic, 329 ; cir- 
cular, 329. 

Dental ulceration, 363. 

Dentition, difficult, 362. 

Depletion, 87 ; local and general, 87 ; 

Dermatitis exfoliativa, 547. 

Dermoid cysts of the skin, 554 ; of 
the neck, 555. 

Deviation of nasal septum, 466. 

Diabetes, 166 ; mellitus, 166 ; in- 
sipidus, 168. 

Diagnosis must precede treatment, 
60. 

Diarrhoea, 393 ; causes of, 393 ; bac- 
teria in, 395 ; summer, 400 ; in 
typhoid fever, 206. 

Diet in typhoid fever, 212 ; relation 
to medication, 62. 

Digestive disorders in rhachitis, 136. 

Digestive organs, 356. 

Digitalis, 518/ in tuberculosis, 180; 
action of, 181 ; preparations of, 
181. 

Diphtheria, 230, 252; bacillus in, 
252 ; streptococcus in, 253 ; local, 
253 ; prevention of, 254 ; contagion 
of, 254 ; self-infection in, 255 ; heart 
failure in, 264 ; stimulants in, 262 ; 
local treatment in, 264 ; nasal injec- 
tions in, 265 ; of the nose, 267 ; of 
eye-lid, 602 ; steam in, 269 ; slak- 
ing lime in, 270 ; adenitis in, 271 ; 
internal treatment of, 272 ; chlo- 
ride of iron in, 272 ; alcohol in, 
273 ; mercury in, 274 ; nephritis 
in, 276 ; paralysis in, 276 ; an- 



titoxin in, 277; immunization 
against, 285. 

Diseases of the blood, 122. 

Disseminated sclerosis, 328. 

Doses of medicines, 68. 

Ductless glands, 155. 

Duodenum in gastric ulceration, 384. 

Dysentery, 219; varieties of, 219; 
food in, 219 ; opium in, 221 ; as- 
tringents in, 221 ; temperature in, 
223 ; paralysis after, 223 ; ulcera- 
tions, 223 ; enemata in, 224; sup- 
positories in, 226. 

Dyspepsia, 45 ; 372 ; causes of, 45 ; 
treatment of, 46 ; alkalies in, 46, 
373. 

Dystrophy, progressive, 315. 

Ear, diseases of the, 587 ; malforma- 
tions, 587 ; foreign bodies in, 587 ; 
eczema of, 588 ; inflammation of, 
588 ; polypus in, 590. 

Eclampsia, 342. 

Ecthyma, 543. 

Eczema, 543 ; seborrhoicum, 546. 

Egg, 42 ; in rectal alimentation, 58. 

Elbow, 581. 

Electricity on skull, 84. 

Elephantiasis, 534. 

Embolism, cerebral, 320. 

Emetic in pseudo-croup, 472. 

Emphysema, 495. 

Encephalocele, 328. 

Enchondroma in mouth, 356. 

Endocarditis, 524 ; chronic, 526. 

Enema. 71. 

Enteritis, 50; treatment of, 50; 
membranous, 389. 

Epicanthus, 596. 

Epidemic cerebro-spinal meningitis, 
213; sequelae of, 214; etiology of, 
215. 



INDEX. 



619 



Epididymis, tuberculosis of, 4G0 ; 
pseudoplasms of the, 460. 

Epilepsy, 348. 

Epileptic dementia, 329. 

Epistaxis, 409. 

Epithelial pearls, 357. 

Ergot in brain-disease, 320 ; in inter- 
mittent fever, 199. 

Erysipelas, 249 ; operations for, 251. 

Erythema, 537 ; nodosum, 296, 539 ; 
papulosum, 296. 

Erythromelalgia, 549. 

Eucalyptus in intermittent fever, 
199. 

Eustachian tube, 591. 

Excursions, 63. 

Exostosis, 563. 

Exomphalos, 119. 

Exophthalmic goitre, 158, 162. 

Expectant treatment, 61. 

Eye, diseases of the, 596 ; malforma- 
tions of the, 596 ; neoplasms, 596 ; 
cysticercus, 597; injuries of, 598; 
burns of, 598 ; afl'ected by medi- 
cines, 599. 

Eyelid, naevus of, 596 ; dermoid 
cysts, 597; lipoma, 597; foreign 
bodies under, 597. 

Facial nerve, paralysis of, 314. 

Factory work, 66. 

Fat diarrhoea, 19. 

Fat food, 136. 

Fat in normal fteces, 19 ; in foods, 
20. 

Fat milk, 39. 

Favus, 550. 

Febrifuges in children, 68 ; in tuber- 
culosis, 184. 

Feeding, forcible, 59 ; through stom- 
ach-tube, 59 ; nasal, 59 ; in ty- 
phoid fever, 203. 



Ferratin, 130. 

Fever, catarrhal, 217; feeding in, 
54 ; typhoid, 200. 

Fibroma in mouth, 356. 

Fingers, supernumerary, 562 ; 
webbed, 563. 

Fissure of the anus, 417 ; of the 
palate, 356. 

Fistula colli congenita, 370 ; in ano, 
187. 

Flat-foot, 584. 

Fomentations, 86. 

Food in anaemia, 125 ; in tubercu- 
losis, 176 ; of cows, 24. 

Foods, artificial, 43. 

Foot, growth of, 582. 

Fractures, 566. 

Frost-bites, 536. 

Fungus, umbilical, 118. 

Funnel chest, 497. 

Furunculosis, 542. 

Gangrene, pulmonary, 497 ; sym- 
metrical cutaneous, 549 ; umbili- 
cal, 109. 

Gargles, 83. 

Gastric catarrh, 378; chronic, 380. 

Gastric neurosis, 383. 

Gastritis, 379. 

Gelatine, 22. 

Genital organs, embryology of the, 
447. 

Genito-urinary organs, 430. 

Genu valgum, 581 ; varum, 581. 

Germs through the anus, 24 ; in 
breast-milk, 24. 

Giant growth, 562. 

Gingivitis, 358. 

Gland, pituitary, 161. 

Glands, ductless, 155. See Lymph- 
bodies. 

Glandular fever. 215. 



620 



INDEX. 



Glandular swellings in diphtheria, 

259. 
Glans penis, 448. 
Glaucoma, 605, 607. 
Glioma of the retina, 597. 
Glossitis, 364. 
Glottis, spasm of the, 477 ; paralysis 

of the, 478. 
Goitre, 155, 161 ; exophthalmic, 

158. 
Gonitis, 579. 

Gonorrhoeal rheumatism, 294. 
Granuloma, 118. 
Green-stick fractures, 139. 
Growing pains, 287. 
Guaiacol in tuberculosis, 182. 
Gum arabic, 22. 
Gymnastics, compulsory, 62 

H asm atom a of the sterno-cleido-mas- 

toid muscle, 98. 
Hsematuria, 432. 
Haemogallol, 130. 
Haemoglobinuria, 432 ; epidemic, 

111. 
Haemol, 130. 
Haemophilia, 163, 531. 
Haemoptysis, 177. 
Hare-lip, 356. 
Hay bacillus, 25. 

Heart, 511 ; acute and chronic dis- 
eases of the, 511; feeding, 511; 

rest, 512 ; exercise, 514 ; cold, 515 ; 

stimulants, 517 ; nitroglycerin, 

522 ; failure, 522 ; syphilis, 528 ; 

congenital anomalies, 528 ; under 

size, 529. 
Heart-failure, 261 ; in typhoid fever, 

209. 
Heart, hypoplasia of, 154 ; in rha- 

chitis, 144. 
Helminthes, 409. 



Hemicrania, 315. 

Hemiplegia, infantile spastic, 328. 

Hemorrhage, gastric, 383 ; in typhoid 
fever, 207 ; pulmonary, 188, 496 ; 
symmetrical cutaneous, 549 ; treat- 
ment of, 122; umbilical, 112; 
vaginal, 458. 

Hemorrhagic diathesis, 163. 

Hepatoptosis, 420. 

Hereditary influences, 134. 

Hereditary syphilis, 189; diet in, 
190; nursing in, 190; preventive 
treatment of, 192 ; medicinal treat- 
ment of, 192. 

Hernia, 119; congenital umbilical, 
119; acquired umbilical, 120 ; in- 
carceration of umbilical, 120; 
inguinal, 120, 413 ; umbilical, 412. 

Herpes tonsurans, 550, 551. 

High temperatures, treatment of, 
203. 

Hip-joint, congenital luxation of the, 
566. 

Hodgkin's disease, 133. 

Hydrargyrum in diphtheria, 274. 

Hydrarthros, 573. 

Hydrencephaloid, 15. 

Hydrocele, 460. 

Hydrocephalus, chronic, 324 ; punc- 
ture in, 327 ; injection into, 327. 

Hydronephrosis, 432. 

Hydropericardium, 528. 

Hydrophthalmos, 607. 

Hydrorrhachis, 340; with tumors, 
340. 

Hydrotherapy, 63. 

Hydrothorax, 510. 

Hymen, imperforate, 458. 

Hyperaemia, cerebral, 319. 

Hypertrophy of pylorus, 381. 

Hypophysis, 161. 

Hypospadias, 448. 



INDEX. 



621 



Ice applications, 86 ; to the cranium, 
86. 

Ichthyol in tuberculosis, 183. 

Ichthyosis, 555. 

Icterus of the newly-born, 113 ; 
hsematogene, 113; hepatogene, 
113. 

Idiocy, 316, 330. 

Immunization, 77. 

Imperforate hymen, 458. 

Impetigo, 543 ; contagiosa, 550. 

Inanition, 10, 62. 

Incontinence of urine, 442, 444. 

Infantile spastic hemiplegia, 328. 

Infarction, pulmonary, 496; uric 
acid, 430. 

Infectious diseases, 169 ; cause of 
rheumatoid diseases, 288. 

Inflammation of nervous system, 318. 

Influenza, 299. 

Infusion of salt water, 15. 

Inhalation, 78 ; through mouth, 79 ; 
through nose, 79 ; through sprays, 
79 ; by filling the room with gases, 
79 ; of muriate of ammonium, 79 ; 
hot steam, 79; turpentine, 79; 
benzine, 80 ; chloroform, 80, 81 ; 
nitrate of amyl, 80 ; oxygen, 80 ; 
ether, 80, 81 ; ozone, 80. 

Injections, subcutaneous, 74. 

Inguinal hernia, 120. 

Insanity, moral, 329. 

Insufflation in asphyxia, 89 ; dan- 
gers of, 89. 

Intermittent fever, 197; types of, 
197. 

Internal secretion, 70, 155. 

Intertrigo, 539. 

Intestinal autoinfection, 538; dis- 
eases, 387 ; mucus, 389 ; tubercu- 
losis, 187. 

Intestines, obstruction of, 61, 



Intubation 475. 

Intussusception, 407. 

Inunctions in hereditary syphilis, 
193. 

Iodide of hydrargyrum in hereditary 
syphilis, 193. 

Iris, gumma in, 597 ; tubercle of, 
597. 

Iritis, acute, 605 ; chronic, 605. 

Iron, preparations of, 129 ; subcu- 
taneous injections of, 130. 

Irritable bladder, 443. 

Jaundice, 422. 

Joints, 562, 572 ; inflammations of 
the, 572 ; tubercular, 573 ; ankle, 
581 ; tarsal, 581 ; elbow, 581 ; in 
rheumatism, 190. 

Keloid, 554. 

Kephalhaematoma, 97 ; causes of, 
97; internal, 97; treatment of, 
97. 

Keratitis, 603 ; parenchymatous, 
604 ; neuro-paralytic, 604. 

Keratoconus, 605. 

Keratomalacia, 599. 

Kidneys, 430 ; malformations of, 
431 ; pseudoplasms of, 431 ; horse- 
shoe, 431 ; tuberculosis of, 431 ; 
echinococcus of, 432 ; hydrone- 
phrosis, 432 ; floating, 432 ; hemor- 
rhage from, 432 ; inflammation of, 
433, 440. 

Knee-joint, congenital luxation of 
the, 566. 

Knock-knee, 581. 

Kreatin, 41. 

Kyphosis, 586. 

Lancing gums, 342. 
Landry's paralysis, 334. 



622 



INDEX. 



Laryngeal diphtheria, uncompli- 
cated, 471. 

Laryngismus stridulus, 143. 

Laryngitis, acute, 471 ; diphtheritic, 
473. 

Larynx, 471 ; acute catarrh of the, 
471 ; uncomplicated, 471 ; in tu- 
berculosis, 185; neurotic affections 
of the, 477 ; neoplasms, 478 ; 
papilloma, 478 ; fibroma, 478 ; 
enchondroma, 478 ; epithelioma, 
478 ; foreign bodies in the, 479 ; 
stricture of the, 479. 

Lateral sclerosis, 334. 

Lateropharyngeal abscess, 367. 

Leontiasis, 554. 

Leucocythaemia, 133. 

Lichen, 540 ; scrofulosorum, 541 ; 
acuminatus, 541 ; planus, 541. 

Lime-water, 36, 49, 385. 

Lipanin, 20. 

Lipomatosis, 154. 

Liver, 419 ; enlargement of the, 
419 ; adenoma of the, 419 ; descen- 
sus of, 420 ; fatty infiltration of, 
420 ; cirrhosis of, 420, 421 ; con- 
gestion of, 422; inflammation of, 
422 ; suppuration of, 422 ; acute 
atrophy of, 422 ; echinococcus of, 
423 ; adenoma of the, 402. 

Locality of medication, 69. 

Lumbar puncture, 323. 

Lungs, 483 ; oedema of, 496 ; hemor- 
rhage of, 496 ; infarction of, 496 ; 
gangrene of, 497 ; p?eudoplasms 
of, 497 ; echinococcus of, 497 ; ac- 
tinomycosis of, 497 ; hernia of, 497. 

Lupus, 550, 551 ; erythematosus, 551. 

Luxation, congenital, 564; of the 
hip, 564 ; of knee, 566 ; of shoul- 
der, 566. 

Lymphangioma, cystic, 534. 



Lymphatism, 153 ; sudden death 
from, 154. 

Lymph-bodies, tumefaction of mes- 
enteric, 401 ; periportal, 402 ; tu- 
berculosis of, 402 ; lymphoma of, 
403 ; sarcoma of, 403 ; syphilis of, 
403 ; intrathoracic, 498 ; bron- 
chial, 498 ; mediastinal, 498 ; in 
rhachitis, 145 ; treatment of, 151. 

Lymph- vessels, 534. 

Macroglossia, 364. 

Mamma, 103 ; secretion of the, in the 
newly-born, 104; angioma in the, 
105. 

Mania, 329. 

Massage, 312. 

Mastitis, 103. 

Mastoid process, 594. 

Masturbation, 447, 458. 

Measles, 230, 241; heart in, 243; 
hemorrhagic, 243 ; respiratory or- 
gans in, 243; larynx in, 244; 
kidneys in, 244. 

Meat of tubercular cows, 175. 

Meconium, aspiration of, 89. 

Medication, relation to dietetics, 62. 

Medicines, effects of, 67 ; absorba- 
bility of, 67 ; fixed doses of, 68 ; in 
brain-disease, 68 ; protracted ad- 
ministration of, 69 ; local adminis- 
tration of, 69; in the rectum, 67, 
72 ; mode of administration of, 66, 
67 ; nasal, 67. 

Melsena, 114; causes of, 115; from 
the nose, 115. 

Melancholia, 329. 

Melasma, 161. 

Membranous enteritis, 389. 

Meningitis, cerebral, 318 ; tubercular, 
321 ; operations in, 323 ; cerebro- 
spinal, 213. 



INDEX. 



623 



Meningocele, 328; spuria, 328. 

Mercury in diphtheria, 274 ; subli- 
mation of, 275 ; in hereditary syph- 
ilis, 192 ; effects of, 68. 

Methylene blue in intermittent fever, 
199. 

Microbes in rheumatism, 288. 

Microcephalus, 316. 

Microphthalmia, 597. 

Microphytes in the air, 177. 

Middle ear, 591. 

Milia, 357. 

Milk, boiled, 65; sterilized, 66; in 
rectal alimentation, 58 ; mixed 
with meat-soup, 40 ; modified, 33 ; 
bone development with, 38 ; of 
lime, 235; of tuberculous cows, 
175 ; should be boiled, 23. 

Milk-sugar, 16. 

Molluscum contagiosum, 550, 551. 

Monomania, 329. 

Moral insanity, 329. 

Mouth, 356. 

Mucous membrane in diphtheria, 
259. 

Mucus, intestinal, 389. 

Muguet, 360. 

Mumps, 245. 

Muscles, diseases of the, 557 ; in 
poliomyelitis, 338. 

Muscular atrophy, 315; paralysis, 
558 ; ischsemic, 558 ; trophoneu- 
rotic, 558; rheumatism, 298, 560. 

Mustard-bath, 84. 

Myasthenia, grave pseudoparalytic, 
559. 

Mj^elitis, transverse, 334. 

Myocarditis, 513, 523, 526. 

Myositis, 557 ; traumatic, 557 ; 
rheumatic, 557 ; infectious, 557 ; 
hemorrhagic, 548 ; syphilitic, 
558 ; tubercular, 558 ; chronic, 



558; ossifying, 558; petrifying. 

558. 
Myotony, congenital, 315. 
Myringitis, 589, 591. 
Myxcederna, 71, 155, 156. 

Naevi on mamma, 105. 

Naevus, 532 ; pigmentosus, 555 ; 
lipomatodes, 555. 

Nares, 463 ; of the new-born, 464 ; 
polypus of the, 467 ; foreign 
bodies in the, 468 ; ulceration of 
the, 470. 

Nasal irrigation. 258, 265; polypus, 
467 ; spray, 258. 

Neck, hygroma of, 555 ; dermoid 
cysts of, 555 ; sanguineous cysts of, 
555 ; of the bladder, 446. 

Nephrectomy, 431. 

Nephritis, 433 ; acute, 435 ; sub- 
acute, 436 ; chronic, 437 ; after 
ether inhalations, 81 ; in diph- 
theria, 276. 

Nephrotomy, 431. 

Nervous diseases in hereditary syph- 
ilis, 196. 

Nervous dyspepsia, 383. 

Nervous system, 311 ; general indi- 
cations of treatment, 311 ; elec- 
tricity in, 312; massage in, 312; 
galvanism in, 313 ; Franklinism 
in, 314 ; operations on the, 316 ; 
inflammation of, 318. 

Neurasthenia, 383. 

Neuroses, 342. 

Neurosis, gastric, 383. 

Neurotic affections of the larynx, 
477. 

Newly-born, epithelial elimination 
in the, 104 ; icterus of the, 113 ; 
treatment of the, 88, 101 ; sur- 
face of the, 102. 



624 



INDEX. 



Night-sweats, 189. 
Night-terrors, 333. 
Nitrate of silver in hlennorrhoea, 

117. 
Nodulated rheumatism, 295. 
Noma, 361; of vulva, 455; of 

vagina, 455. 
Normal serum, 278. 
Nose, diphtheria of the, 267. 
Nuclein, 28. 
Nucleon, 28. 

Oatmeal, 22. 

Obesity, 162. 

Obstruction, mechanical, 387. 

(Edema, pulmonary, 496. 

(Esophagus, 371 ; stricture of, 371 ; 

foreign bodies in, 371. 
Oidium, 360. 

Ointments, 86 ; in nose, 83. 
Oleates, 86. 
Omphalitis, 109. 
Omphalo-mesenteric duct, 118. 
Operations in tuberculosis, 185. 
Optic nerve, 607. 
Oral cavity, 356 ; tumors in, 356. 
Oral secretion, 11. 
Orbit, 607. 
Orchitis, 460. 

Organotherapy, 70, 78, 162. 
Osteochondritis, 567. 
Osteoclasy, 139. 
Osteoma in mouth, 357. 
Osteomyelitis, 567. 
Osteotomy 139. 
Ostitis, 567 ; tubercular, 567. 
Otitis externa, 588; catarrhal, 589; 

phlegmonous, 590; media, 591. 
Ovaries, pseudoplasms of the, 461. 
Oxaluria, 445. 

Oxygen, 80 ; inhalations of, 130. 
Ozone, 80. 



Palate, fissure of, 356 ; syphilitic 
perforations of, 358 ; diphtheritic 
perforations of, 358. 

Pancreas, 11, 37. 

Papilloma of the skin, 548. 

Paralysis, diphtheritic, 276. 

Paramyoclonus, 334. 

Paraphimosis, 455. 

Paratyphlitis, 406. 

Paresis, 324, 329. 

Parotid, 11, 13 ; adenoma of, 356. 

Parotitis, 362. 

Pasteurization, 26. 

Pavor nocturnus, 333. 

Peliosis rheumatica, 163, 295. 

Pemphigus, 546; in hereditary syphi- 
lis, 194 ; contagious, 547 ; folia- 
ceus, 547 ; exfoliativus, 548 ; neu- 
roticus chronicus, 548. 

Peptone, 41 ; digestibility of, 42 ; 
disturbs digestion, 14. 

Peptonized beef preparations, 41. 

Pericarditis, 527 ; operations in, 528. 

Perichondritis, 567. 

Perimastitis, 103. 

Periodic night cough, 483. 

Pericesophageal abscess, 371. 

Periostitis, 567 ; albuminous, 567. 

Perisplenitis, 424. 

Peristalsis, incomplete, 51, 389. 

Peritonitis, 425; suppurative, 428; 
tubercular, 428 ; laparotomy in, 
428 ; chronic, 428. 

Pernicious anaemia, 132 ; causes of, 
132; bone-marrow in, 133; treat- 
ment of, 133. 

Pertussis, 300; prevention of, 300; 
catarrh in, 301 ; air in, 301 ; com- 
pressed air in, 302 ; local treat- 
ment in, 302; rest in, 303; inhala- 
tions in, 304 ; quinine in, 304 ; 
tussol in, 305 ; belladonna in, 305 ; 



INDEX. 



625 



opium in, 309 ; oxymel scillse in, 
309 ; bromoform in, 310. 

Pes varus, 582 ; equinus, 583 ; cal- 
caneus, 583 ; valgus, 584. 

Pharyngitis, 365 ; catarrhal, 365 ; 
phlegmonous, 306 ; erysipelatous, 
366. 

Pharynx in tuberculosis, 186. 

Pbimosis, 451 ; operation of, 453. 

Phlebitis, umbilical, 109; diagnosis 
of, from arteritis, 110. 

Phlegmonous gangrene, 361. 

Phosphaturia, 445. 

Phosphorus, 141. 

Phthisis, 170. 

Pigeon-breast, 138. 

Pituitary gland, 161. 

Pityriasis lingua?, 364. 

Placenta, removal of, 89. 

Play, 62. 

Pleura, 499. 

Pleurisy, 499 ; operation in, 501 ; 
compression of lung by, 502 ; ex- 
plorative puncture in, 502; local- 
ized, 504 ; uncomplicated, 505 ; 
thoracocentesis, 506 ; hemorrhagic. 
507 ; purulent, 508. 

Pneumonia, 483 ; lobar, lobular, in- 
terstitial, 484 ; temperature in, 
486 ; dangers of, 486 ; quinine in, 
487; cold in, 488; warmth in, 
488; alcohol in, 490; digitalis in, 
490; stimulants in, 492 ; poultices 
in, 493 ; complications of, 494 ; 
hypostatic, 495 ; interstitial, 495 ; 
caseous. 170. 

Poliomyelitis, 334, 337; club-foot 
after, 339. 

Polyneuritis, 315. 

Postnatal asphyxia, 94. 

Potassium iodide in hereditary 
syphilis, 195. 



Prepuce, 449 ; adhesion of the, 449 : 

diphtheria of the, 454. 
Preventive treatment, 62. 
Progressive juvenile muscular dys- 
trophy, 315. 
Prolapse of anus and rectum, 414. 
Prurigo, 540, 541. 
Pseudohypertrophy, 161, 315. 
Pseudoleukemia, 133. 
Pseudo-membranes, 252. 
Pseudo-membranous croup, 473. 
Pseudoparalysis, 559. 
Pseudoplasms of the epididymis, 

460 ; ovaries, 461. 
Psoriasis, 553. 
Psychical diseases, 329 ; causes of, 

331. 
Pneumothorax. 510. 
Puerperal sepsis, 110. 
Pulmonary hemorrhages, 188, 496 ; 

oedema, 496. 
Puncture in hydrocephalus, 327 : 

lumbar, 323. 
Pupil, atresia of the, 596. 
Purpura in infectious diseases, 296. 
Pylorus, congenital hypertrophy of, 

381. 
Pyopneumothorax, 510. 

Eanula. 357. 

Eectal alimentation, 57. 

Rectal injections of medicines, 71 ; 
constituents of, 73, 74 ; large, 73. 

Eectum, 71 ; catarrh of, 414, pro- 
lapse of, 414 ; polypus of, 418. 

Reflex contraction of the bladder. 
446. 

Relapsing fever, 213. 

Renal calculi, 439. 

Renal diseases, feeding in, 57. 

Respiratory diseases, feeding in, 56 ; 
organs, 463 ; in rhachitis, 144. 



40 



626 



INDEX. 



Retention of urine, 443. 

Retina, 597, 607 ; glioma of, 597. 

Retropharyngeal abscess, 367. 

Rhachitis, 52, 134 ; hygiene in, 235 ; 
sanitaria in, 135 ; air and food in, 
135 ; bathing in, 136 ; cod-liver 
oil in, 137 ; thyreoid in, 137 ; malt 
in, 138 ; bones in, 138 ; osteoclasy 
in, 139 ; osteotomy in, 139 ; in- 
fractions, 139 ; scoliosis in, 140 ; 
craniotabes in, 140 ; brain in, 141 ; 
respiratory organs in, 144 ; laryn- 
gismus in, 143 ; constipation in, 
146 ; due to digestive disorders, 
136. 

Rheumatism, 285 ; endocarditis in, 
286, 292; frequency of, 285; 
monarthritis in, 287 ; of the cer- 
vical column, 288 ; microbes in, 
288 ; after infectious diseases, 288 ; 
prevention of, 290 ; joints in, 290 ; 
cold in, 290 ; vesicatories in, 291 ; 
chorea in, 292; temperature in, 
292 ; remedies in, 293 ; gonor- 
rhoeal, 294 ; nodulated, 295 ; pelio- 
sis, 295 ; erythema in, 296 ; 
chronic articular, 297, 571 ; mus- 
cular, 298, 560 ; feeding in acute, 
57. 

Riga's disease, 363. 

Rotheln, 245. 

Rubella, 245. 

Rupia, 543. 

St. Vitus's dance, 343. 

Salaam spasm, 354. 

Saliva, 11, 13, 37 ; when in the 
stomach, 12, 13. 

Sarcoma, 77 ; of the skin, 554. 

Scabies, 549. 

Scarlatina, 226 ; origin of, 227 ; con- 
tagion of, 227 ; invasion of, 228 ; 



school-inspection in, 228 ; inunc- 
tion in, 229 ; prevention in, 229 ; 
directions to prevent, 230; dis- 
charges in, 233 ; throat complica- 
tions, 235 ; diphtheria antitoxin in, 
236; glands in, 236; febrifuges 
in, 237 ; rheumatism in, 237, 238 ; 
toxic symptoms in, 237, vomiting 
in, 237 ; joints in, 238 ; heart in, 
238; complications of, 239, 240; 
hemorrhages in, 239 ; pemphigus 
in, 239 ; nephritis in, 240 ; strepto- 
coccus antitoxin in, 241. 

School hours, 332 ; inspection, 228 ; 
vacations, 62. 

Sclerema, 99. 

Scleroderma, 549. 

Sclerosis, disseminated, 328 ; amyo- 
trophic lateral, 334 ; multiple dis- 
seminated, 334. 

Scoliosis, 585. 

Scorbutic rhachitis, 143. 

Scrofuloderma, 552. 

Scrofulosis, 147 ; preventives of, 
148; foods in, 149; medicines in, 
149. 

Scurvy, 163 ; infantile, 165. 

Seborrhcea, 540. 

Secretion, internal, 70, 155. 

Semi-cretinism, 71, 156. 

Sepsis, puerperal, 111. 

Serumtherapy, 77. 

Shoulder, congenital luxation of the, 
566. 

Sigmoid flexure, 121. 

Sinapism, 84. 

Skin, diseases of the, 535 ; in tuber- 
culosis, 178 ; neuropathic affec- 
tions of the, 548 ; papilloma of 
the, 548 ; oedema of the, 548 ; cya- 
nosis of the, 548 ; peculiarities of, 
84 ; tuberculosis of the, 552 ; con- 



INDEX. 



627 



genital diseases of the, 553 ; neo- 
plasms of the, 553 ; lipoma, 553 ; 
fibroma, 554; cysts, 554; keloid, 
554 ; atheroma, 554 ; sarcoma, 
554 ; atrophy, 555. 

Sodium bicarbonate in milk, 37 ; 
chloride, 17; physiological effects, 
17, 19. 

Solutions on skin, 86. 

Somatose, 43. 

Spasm of the glottis, 477. 

Spasmus nutans, 354. 

Spermin, 131. 

Spina bifida, 340 ; ventosa, 567. 

Spinal canal, 333. 

Spinal cord, arrest of development, 
333. 

Spinal inflammation, 333 ; treatment 
of, 335. 

Spinal pachymeningitis, 334 ; lepto- 
meningitis, 334. 

Spleen, 424 ; embolism of, 424 ; ab- 
scess of, 424 ; in typhoid fever, 
212. 

Splenic anaemia, 134. 

Spondylitis, 569 ; tubercular, 570. 

Sprays, 79. 

Stammering, 355. 

Starch changed into dextrin in the 
rectum, 58 ; transformation of, 11. 

Steam, 79 ; in diphtheria, 269. 

Sterilization, 25; not effective in 
killing bacteria, 25 ; separates 
cream, 27 ; at home, 26. 

Sterilized milk as exclusive food, 29. 

Sterno-cleido-mastoid muscle, hema- 
toma of, 98. 

Stimulants in typhoid fever, 209. 

Stomacace, 358. 

Stomach, 372 ; dilatation of, 381 ; 
the infantile, 46 ; ulceration of, 48, 
383. 



Stomatitis, 358 ; follicular, 358 ; ul- 
cerous, 358 ; aphthous, 359 ; mem- 
branous, 360; infectious, 361. 

Strabismus, 607. 

Strophulus, 541. 

Styptics, 87. 

Subcutaneous injections, 74 ; localities 
of, 74 ; doses of, 75 ; of alkaloids, 
75 ; quinine in, 76 ; pilocarpine in, 
76 ; morphine in, 75 ; strychnine 
in, 76; caffeine in, 77; Fowler's 
solution in, 77. 

Sublimation of mercury, 275. 

Submaxillary glands, 11. 

Substitutes for breast-milk, 21. 

Sudden deaths, 154, 160, 161. 

Sugar, 16 ; in different milks, 16. 

Supernumerarj 7 fingers, 562. 

Suppositories, 74. 

Suprarenal melasma, 161. 

Surface of the newly-born, 102. 

Symmetrical cutaneous hemorrhage, 
549 ; gangrene, 549. 

Synechia of fingers, 563. 

Syphilis, 189; of the newly-born, 
114. 

Tabes, 334. 

Taenia, 409. 

Taka-diastase, 12. 

Tarsal-joints, 581. 

Teleangiectasia, 532. 

Temperature reduced by water, 63 ; 
influence of elevation of, 64 ; re- 
duction by drugs, 64 ; reduction 
of, in the newly-born, 102. 

Testicle, syphilis of the, 460. 

Tetanus, 115, 340 ; preventive of, 
116; bacillary, 116; rheumatic, 
116. 

Tetany, 345. 

Therapeutics, general, 60. 



628 



INDEX. 



Thiersch's solution, 109. 

Thomsen's disease, 315. 

Throat, 365. 

Thrombosis, 531 ; cerebral, 320. 

Thrush, 360. 

Thymus, 160. 

Thyreoid gland, 70, 155 ; carcinoma 

of, 155 ; tuberculosis of, 155 ; 

syphilis of, 155; atrophy of, 155; 

inflammation of, 155 ; uses of, 

155, 160. 
Toes, congenital enlargements of 

the, 562. 
Tongue, 363 ; congenital anomalies 

of, 363 ; bifid, 363 ; sarcoma of, 

363 ; lipoma of, 363 ; dermoids of, 

364 ; hygroma of, 364 ; lymphan- 
gioma of, 364 ; adhesion of, 364 ; 
in tuberculosis, 186 ; sarcoma of, 
356. 

Tonsil, 365 ; parenchymatous in- 
flammation of, 366 ; in diphtheria, 
258. 

Tonsillitis, 365. 

Torticollis, 559. 

Trachoma, 602. 

Transverse myelitis, 334. 

Treatment, expectant, 61 ; pre- 
ventive, 62. 

Trismus, 115. 

Tubercular meningitis, 321 ; opera- 
tions in, 323. 

Tuberculin, 183. 

Tuberculocidin, 183. 

Tuberculosis, 169 ; dissemination of, 
169 ; acute miliary, 170 ; preven- 
tion of, 171; causes of, 172; he- 
redity in, 173 ; direct transmission 
of, 173 ; food in, 176 ; climate in, 
176; water in, 179; arsenic in, 
179; digitalis in, 180; larynx in, 
185; of the skin, 552. 



Tumor albus, 572. 

Turkish bath, 515. 

Turpentine, inhalations of, 185. 

Tussol, 305. 

Tympanites in typhoid fever, 205. 

Typhoid fever, 200; feeding in, 
55 ; dangers of, 200 ; diagnosis of, 
200; preventive treatment of, 
201 ; abortion of, 201 ; antifer- 
mentatives in, 201 ; expectant 
treatment of, 202; feeding in, 

203 ; complications with bronchitis 
in, 203 ; high temperatures in, 203 ; 
cold water in, 204; medicines in, 

204 ; tympanites and meteorismus 
in, 205 ; diarrhoea in, 206 ; consti- 
pation in, 207; preparations in, 
207 ; hemorrhages in, 207 ; heart- 
failure in, 208 ; brain symptoms 
in, 209; stimulants in, 209, 210; 
the brain in, 211; posture of 
head in, 211; opiates in, 211; 
convalescence from, 212 ; sequela? 
of, 212 ; muscles in, 212 ; bones in, 
212 ; noma after, 212. 

Typho-malaria, 213. 
Typhus, 213. 

Ulceration, gastric, 383 ; alkalines 
in, 384; diet in, 385; anoemia in, 
386 ; of stomach, 48 ; treatment 
of, 49. 

Umbilical fungus, 118 ; gangrene, 
109 ; arteritis, 109 ; phlebitis, 
109; hemorrhage, 112; before the 
separation of the cord, 112; after 
the separation of the cord, 112; 
hernia, 412. 

Urethra, epithelial obstruction of 
the, 448 ; membranous obstruction 
of the, 448 ; stricture of, 448. 

Uric acid infarction, 31, 430. 



INDEX. 



G29 



Urine, retention of, 442, 443 ; incon- 
tinence of, 442. 
Urticaria pigmentosa, 548. 

Vaccinia, 247. 

Vagina, atresia of the, 458 ; noma 
of the, 455. 

Vaginal catarrh, 456 ; hemorrhage, 
458. 

Varicella, 247. 

Variola, 226 ; vaccination and re- 
vaccination, 246. 

Vascular diseases, 527. 

Veal broth, 41. 

Veins, thrombosis of, 531. 

Verrucse planae juveniles, 548. 

Vertebrae, tuberculosis of, 569. 

Vesicatories. 84 ; contraindications 
to, 85. 

Vitiligo, 548. 

Vitreous body, abscess of, 606. 

Vomiting, 46. 



Vulva, noma of the, 455. 
Vulvar catarrh, 456. 
Vulvitis, aphthous, 454. 

Warts, 548. 

Water, cooling by, 64 ; stimulation 
by, 64 ; application of, 65 ; water- 
ice, 15; in food, 14; in pepsin 
digestion, 14; in tuberculosis, 
179; in laryngitis and bronchitis, 
15 ; in constipation, 15 ; should be 
boiled, 15; protects the kidneys, 
431. 

Weil's disease, 213. 

Werlhof's disease, 163. 

Wet-nurse in hereditary syphilis, 
191. 

Whooping-cough. See Pertussis. 

Wine, 45. 

Xerosis, 604. 



THE END. 




mmsssm 

mm 



LIBRARY OF CONGRESS 

022 216 205 * 



■HM 

MJBH 



96888888 

HHmbm 

DHHBBMC 

H 

■hh 



nor - 



ftS 



gg8 « 88gggaj 



lira 

isi 

BBS 
fflsBSSBBBi 



m 



Hi 



IB 



mSBT 

9 Shi 



88888888889 



■ 

JdHHHhL 

a on i B Ptwoo o w 
II 



H 



ig s ii isgBB 



gO M Ml 



JSSjggjjS 

in 



